How can mental health and faith-based practitioners work together? A case study of collaborative mental health in Gujarat,India

Abstract

Despite the knowledge that people with mental illness often seek care from multiple healing systems, there is limited collaboration between these systems. Greater collaboration with existing community resources could narrow the treatment gap and reduce fragmentation by encouraging more integrated care. This paper explores the origins, use, and outcomes of a collaborative programme between faith-based and allopathic mental health practitioners in India. We conducted 16 interviews with key stakeholders and examined demographic and clinical characteristics of the user population. Consistent with previous research, we found that collaboration is challenging and requires trust, rapport-building, and open dialogue. The collaboration reached a sizeable population, was reviewed favourably by key stakeholders—particularly on health improvement and livelihood restoration—and perhaps most importantly, views the client holistically, allowing for both belief systems to play a shared role in care and recovery. Results support the idea that, despite differing practices, collaboration between faith-based and allopathic mental health practitioners can be achieved and can benefit clients with otherwise limited access to mental health care.

Keywords

collaboration community mental health faith-based services India low- and middle-income countries psychiatry

Introduction

Approximately 70 million people in India suffer from mental illness, and the treatment gap¹ is estimated to be 47% for severe mental disorders and 82% for common mental disorders (Directorate General of Health Services Ministry of Health and Family Welfare, 2011; Ganguli, 2000; Ministry of Health and Family Welfare Government of India, 2005; Reddy & Chandrashekar, 1998; Sinha & Kaur, 2011; Thirunavukarasu, 2011). India’s pluralistic system means that people with mental health problems consult different local systems of healing, which can include, but are not limited to, Indian medicine (Ayurveda, Unani, Siddha, and homeopathy), allopathic services, and folk or faith healing systems (Halliburton, 2009; Sarin & Jain, 2013). These systems operate in parallel and there is limited collaboration between them. Given this plurality, an understanding of local systems of healing and the communities using them is key to efforts to reduce the mental health treatment gap (Campbell & Burgess, 2012; Campbell-Hall et al., 2010; Davar, 2014; Desjarlais, Eisenberg, Good, & Kleinman, 1996; Kleinman, 1980; Patel, 2011).

Collaboration might provide solutions for several current challenges of the allopathic mental health system in India by utilizing existing local resources for the provision of mental health care (Abbo et al., 2008; Gureje & Lasebikan, 2006; Horton, 2007; Kayombo et al., 2007; Saraceno et al., 2007; World Health Organization, 2002). The first challenge is the human resource crisis; there are too few allopathic mental health professionals to respond to the needs of the population, and the majority are based in urban areas, leaving 90% of rural areas without access to care (Khandelwal, Jhingan, Ramesh, Gupta, & Srivastava, 2004; Weiss, Isaac, Parkar, Chowdhury, & Raguram, 2001). Practitioners in other systems could therefore constitute a local resource which could be harnessed to facilitate care for mental health problems (Ae-Ngibise et al., 2010). In India, faith-based healers (FBH) are widely consulted for both general and mental health problems (Campion & Bhugra, 1997; Carstairs & Kapur, 1976; Kar, 2008), and places of worship are often viewed as providing cures for ailments and problems (Padmavati, Thara, & Corin, 2005; Raguram, Venkateswaran, Ramakrishna, & Weiss, 2002). Studies report that 31% to 69% of people with mental health problems seek help from faith-based healers (Campion & Bhugra, 1997; Chadda, Agarwal, Singh, & Raheja, 2001; Kar, 2008; Kulhara, Avasthi, Sharma, Kulhara, & Avasthi, 2000; Lahariya, Singhal, Gupta, & Mishra, 2010; Wagner, Duveen, Themel, & Verma, 1999). Explanatory models that attribute the cause of mental illness to supernatural occurrences or to previous wrongdoings lead sufferers to seek relief through rituals and practices performed by FBH (Kar, 2008; Kishore, Gupta, Jiloha, & Bantman, 2011; Kulhara et al., 2000).

A second challenge that can be addressed by collaboration is that because mental illness is highly stigmatized in India, seeking treatment at a psychiatric hospital or clinic may exacerbate the stigma faced by clients and their families (e.g., Wig, 1997). As a result, people often choose to conceal their mental health problems, or address them by seeking help from FBH, whose practices are rooted in the local culture, and therefore perceived as less stigmatizing and better aligned with community perspectives and beliefs (Davar, 2014; Selvaraj & Kuruvilla, 2001).

Research exploring enablers and barriers to cooperation between FBH and allopathic mental health practitioners (AMHP) globally is limited. There has not been extensive research on how providers in various local systems collaborate or relate to each other (Kleinman, 1980, p. 26). With regard to the configuration of collaboration across local healing systems, scholars in the African context have put forth several models for how allopathic and faith-based systems may interact: incorporation, collaboration/cooperation, and total integration (Freeman & Motsei, 1992). Incorporation involves FBH incorporated into the health care system within a primary care approach as first-line health practitioners (Freeman & Motsei, 1992). In cooperation/collaboration traditional and allopathic health systems remain autonomous and retain their own practices and methodologies, while practitioners from the two systems co-operate through recognition of the importance and value of both systems and mutual referral of patients. Total integration refers to the evolution of a new and blended system, in which both systems provide one packaged treatment. More recently, debate in this area has shifted from the type of interaction between systems to how the allopathic mental health and faith-based sectors can collaborate to bridge the gap in care and treatment, recognizing that these two systems often work in parallel (Hansdak & Paulraj, 2013).

Although collaboration between allopathic and faith-based systems could contribute to reducing the fragmentation arising from parallel but disconnected systems, scepticism regarding the value of faith-based systems persists. In particular, human rights abuses of persons with mental illness in faith-based healing services are one of the main obstacles to collaboration between allopathic mental health and faith-based services (Ae-Ngibise et al., 2010). In India, allopathic practitioners’ mistrust of faith-based mental health care was reinforced by the Erwadi tragedy in 2001 that claimed the lives of 25 persons with mental illness. The victims were on the premises of a Muslim dargah (the shrine of a saint) for treatment and were not able to escape a fire because they were shackled in the dargah’s hostel. The tragedy instigated a nationwide outcry about human rights violations of the mentally ill at religious sites, resulting in widespread apprehension towards care provision by these sites (Antony, 2002; Davar, 2014; Murthy, 2001; Selvaraj & Kuruvilla, 2001; Trivedi, 2001). On the other hand, human rights violations have also been reported in allopathic mental health facilities in India (Murthy, 2001). Nevertheless, when collaboration between the two systems adopts a rights-based approach to care, faith-based care may become an ally of psychiatry as illustrated by the Dava Dua Programme.

The Dava Dua Programme (DDP)

In the aftermath of Erwadi, and in the context of scarce resources for allopathic mental health services, many accessing faith-based services for mental illness were left with no other options for care. This prompted the development of innovative programmes to support rather than condemn FBH and the search for new forms of cooperation that could help prevent the occurrence of such tragedies. One such initiative is the DDP, a collaborative initiative in community care initiated by AMHPs aiming to facilitate treatment and protect the rights of those with mental health problems. Allopathic and faith-based approaches coexist in the programme, simultaneously providing culturally acceptable services and facilitating the protection of the rights of persons with mental illness. The name reflects this coexistence of different systems and is derived from Dava and Dua, which in the programmatic context refer to biomedical psychiatry (counselling and medication) and prayers. In Urdu and Hindi these two words can have broader definitions. For instance Dua can signify a source of spirituality, and can entail a simple prayer, or a religious or spiritual ritual.

The DDP started as a working partnership between FBH from the Mira Datar dargah and AMHPs in Unava, a village 100 kilometres from Gujarat’s capital, Ahmedabad. The Mira Datar dargah is renowned for working with mental and behavioural problems related to the supernatural, and has been previously studied through ethnographic research (Pfleiderer, 1988). After 3 years of communication and sensitization, a formal programme was launched in March 2008. This marked the start of a more intensive, multifaceted approach to rural community mental health. In addition to FBH, other community leaders were involved and workshops; community discussions; and information, education, and communication activities were held in the community. In the same year, FBH declared their support and permitted AMHPs to start a psychiatric outpatient clinic in the dargah. The collaboration was envisaged as a complementary approach to addressing problems and complaints. As part of the collaboration, clients who visit the FBH for completion of rituals can be referred by FBH to AMHPs at the clinic if the FBH detect mental health problems. In addition to their rituals with FBH, clients can receive medication and basic counselling at the clinic colocated in the dargah. AMHPs also refer clients back to FBH for addressing problems which clients feel could be resolved through spiritual rituals. Linkages were established with the public health sector, and the state government ensures that medication is free for clients in the programme. Clients with more severe mental health problems are referred to the government-run psychiatric hospital in the city of Ahmedabad.

To our knowledge, the DDP is unique as other examples of sustained cooperation between FBHs and AMHPs are uncommon. Documenting the start-up of this programme and its evolution thus provides an opportunity to understand how fragmentation between these two systems might be reduced and the potential for collaboration to be included in plans and policies. To date, the potential benefits of such community-based collaborations have not been well documented in policies despite the fact that the state of Gujarat (where the DDP is situated) drafted its mental health policy during the development of the DDP. This paper therefore aims to contribute to the understanding of how integrated care might be provided by documenting the process of establishing the DDP as a working partnership between FBHs and AMHPs. In this article, we focus on three broad research questions: (a) How was collaboration established and what are the barriers and enablers to collaboration? (b) Who are the users accessing services from this programme? and (c) What are provider and client experiences with the programme?

Methodology

Design

This was a mixed-methods case study. Qualitative data aimed to shed light on how the DDP collaboration was realized, trajectories of clients and carers accessing the DDP, and different stakeholders’ experience with the programme; quantitative data provide information on the demographic and clinical characteristics of those who accessed the DDP.

Qualitative methods

Semistructured interviews were conducted with key stakeholders instrumental in the setup and maintenance of the DDP. This included AMHPs (n = 3) and FBHs (known locally as mujavars; n = 3). Accounts of experiences with the DDP were also collected from clients (n = 3) and their carers (n = 7). We employed convenience sampling based on a selection of clients and carers attending the DDP during March 2013. Efforts were made to invite clients and carers to participate in interviews who were representative of both genders, different socioeconomic conditions, and different religious backgrounds. An overview of interviewees is presented in the supplementary material which is available online with this article.

The topics of the interviews differed by stakeholder. Interviews with key stakeholders (AMHPs and FBHs) centred on the perceived impact the DDP had in the community, and perceived essential components of the DDP collaboration. Both AMHPs and FBHs were asked about their experience with referrals and any apprehensions they had felt about collaborating. For clients and carers, interviews focused on initial mental health problems, pathways to care, motivation for continuing to receive care from the DDP, and perception of care and services before and during treatment at the DDP.

Sixteen semistructured interviews were conducted with stakeholders at their location at the time of data collection (14 in Unava, Gujarat, one at the Hospital for Mental Health, Ahmedabad, Gujarat and one in Pune, Maharashtra) in the local language (Gujarati), Hindi, or English, by two of the authors: a field researcher who is part of a nongovernmental organization working with the DDP and an external researcher. All interviews were recorded (either video or audio or both) and transcribed verbatim. All interviews were translated into English and back-translated into either Gujarati or Hindi to ensure that words used throughout the interview maintained their original meaning. A subsample of the interview transcripts was sent for member check, which resulted in modifying the transcript for one of the interviews due to different conceptual understandings of faith-related healing practices. The modifications resulted in a clearer understanding for presentation in the thematic analysis. Field notes were also included and added to the interviews.

A thematic analysis approach was employed for the interviews (Miles & Huberman, 1994). The coding process consisted of several stages. Stage 1 involved two researchers familiarizing themselves with the interview data. In Stage 2, two researchers independently coded the data inductively and generated a list of emergent codes. The codes generated were collated and refined into potential themes relevant to the three research questions. Disagreements about coding selections were resolved through discussion, and involvement of a third researcher when necessary. Transcripts were recoded independently according to the developed coding scheme documented in a codebook. Themes were then defined and named. Key themes included the process of developing the Dava Dua collaboration, barriers and enablers to collaboration, care pathways (client code), and experience with the DDP (client, carer, and provider code). All emergent themes were then clustered according to the three research questions: how collaboration was established; the user population accessing care at the DDP; and stakeholders’ experiences with the DDP. Interviews were analyzed in MAXQDA (Version 11).

Quantitative methods

The quantitative analysis involved descriptive statistics of the characteristics of clients recorded in the database of the DDP. All clients who accessed and received care from the DDP between April 2008 and March 2013 (n = 3,172) were included. Available data on the 3,172 clients were analyzed with SPSS (Version 20) and included demographic variables (sex, age, educational status, marital status, religious preferences) and clinical variables (diagnosis, age of onset, referral pathways, mode of treatment) from the client database. Diagnoses had been made according to ICD-10 diagnostic criteria by psychiatrists working at the DDP. As the DDP was initiated to fill the service gap in this particular area of Gujarat, standardized outcome measures or rating scales were not included within the programme.

Ethical considerations

Local ethical approval was obtained from the Ahmedabad Hospital for Mental Health. Consent to participate in the interviews was obtained and recorded from every participant. In three of the seven interviews with carers, the clients (separate from the client interviews) were present but had limited participation in the interview. To ensure confidentiality during the data analysis, names and identifying information were replaced with unique ID codes based on stakeholder type: service user (U), carer (C), faith healer (FBH), or mental health practitioners (AMHP).

Results

How was the collaboration brought about?

Establishing the DDP collaboration was a lengthy process initiated by AMHPs. The following sections detail barriers to initial collaboration as well as strategies used to overcome these barriers.

Barriers to initial collaboration

One key challenge to collaboration expressed by the AMHPs was the apprehension of FBH. This apprehension appeared to arise from the perception that AMHPs were intruding on FBHs’ territory and posed a threat to their livelihood:

My first visit in 2004, when I approached all the FBHs … they initially opposed, [saying] … this [dargah] is a religious place, no government agencies are allowed … this is a family trust … religion and faith are not to be mixed up with the government … so they opposed many times. More than 40 to 50 FBHs refused me to enter into the dargah. Then I called police officers and district collectors to help me … and then I talked with key FBHs and one or two trustees … I want to see the place, what’s happened, what activities you are doing, and report to the government. Explicitly I’m keenly interested in the conditions of persons attending this dargah, especially … mentally ill persons [the FBH told me] … “here anybody can come, suffering from any problem.” Initially they said that “they all are having effect of evil or ghost … There’s not anyone suffering from mental illness”—so no role of yours. (ID 15, AMHP)

The apprehension of the FBHs is here described from the perspective of the AMHPs, and this particular AMHP mentioned that it took many months of repeated visits to the dargah and many attempts to communicate with FBH leaders to gain trust and show that the work of the AMHPs would not impose on the work of the FBHs.

AMHPs were also apprehensive about collaborating with FBHs due to the perceived differences in professional and societal status between them, making partnership difficult: “Initially, practitioners said this is not possible because doctors’ and faith practitioners’ status are different” (ID 15, AMHP). Resolving the apprehension on both sides was achieved gradually through discussions between AMHPs and key FBHs who supervised other FBHs, allowing time for practitioners to adjust to both allopathic and faith-based practices. Some of the strategies employed are described below.

Building trust and rapport

One of the most important elements in the start-up of the DDP was gradually and carefully developing and evolving strategies focused on building rapport and trust. The initiators of this trust-building process were a small number of AMHPs, who simultaneously held multiple roles within the allopathic system, working in either academic institutions or hospitals as well as for the government; they therefore can be considered as intermediaries in the process of establishing collaboration, consolidating commitment from all of these stakeholders. Three main rapport-building strategies emerged in the interviews. One strategy was to ensure a continuous and open dialogue to promote mutual understanding of each other’s work. One interviewee spoke about his off-duty visits to the dargah to engage with FBHs when there was still substantial apprehension towards collaboration. Another strategy was to ensure that FBHs felt important and respected for their expertise and work. This respect was evidenced by the cross-referral of clients back to FBHs after consultations with AMHPs. A third rapport-building strategy was to emphasize that AMHPs and FBHs were not in competition, and to encourage mutual support and respect of practices and knowledge. Practicing respect for faith-based services meant refraining from belittling practices or comparing them to the allopathic system. As a practical example, this included AMHPs and FBHs sitting together on the floor for client consultations (rather than on chairs) to symbolize equality:

These FBHs perceive that they are therapists, they also say that … religious-faith based services are giving some relief, so we also respect their belief and their thoughts … and also in this project we ensure that the therapist respect and dignity is maintained … and that the doctors are performing same work [as FBHs]. So FBHs sitting on floor … doctors also sitting on the floor … giving equality, rather than discrimination. (ID 15, AMHP)

Trust was built by developing a shared, unified goal based on common values to consistently refer back to throughout the beginning stages of the partnership: “Both doctors and priests work together for the same shared goal, for the benefit of the client. If this is the case, there is no competition or challenges” (ID 16, AMHP).

Once trust was established between the AMHPs and FBHs, some FBHs and their family members came forward with their own mental health problems, illustrating the amount of trust that FBHs invested in the programme and their AMHP colleagues:

So they started believing in the system and this service … and slowly and gradually they also had some family members who were suffering with mental illness. So they came forward, with their family members. (ID 13, AMHP)

Training and sensitization activities

Extensive sensitization and training were provided to FBHs by AMHPs on identifying symptoms of mental illness, referral strategies, and the referral process. Training modules included roles and expectations in the partnership, basic detection of mental illness and mental health problems, and how and when to refer clients. Following these modules were refresher training and awareness-raising sessions with both FBHs and the surrounding community. A common thread throughout all sensitization and training activities was the notion that referral by FBHs to AMHPs was optional rather than compulsory, thus reinforcing the idea of mutual respect: “We train FBHs how to identify, who to refer, when to refer, and made clear that it is not a compulsion for them to refer. It is their own free will to refer a person” (ID 16, AMHP).

The sustained, routine sensitization activities helped with improving mental health literacy for both the FBHs and the wider community.

We did rapport building exercises with them … focus group discussions with FBHs, all ages, in groups of five to seven people and explain to them … what is mental health, what is the project, how is it important for you, how will your interests be safeguarded … Doctors also sat in on the discussions to understand. This process took 6–8 months. (ID 16, AMHP)

Driven by the AMHPs, the aim was to train and empower FBHs to act as community mobilizers for mental health and as liaisons between the clients and AMHPs. This was done in view of the fact that the FBHs had much more direct contact with and were more respected by the communities.

Learning and openness

In turn, FBHs were positive about the training received on mental illness identification and referral. The sensitization and training activities led to a reconceptualization of clients’ problems, drawing a distinction between “physical” problems (which, from the FBHs perspective, related to mental health problems) and problems related to the supernatural. This shift occurred when FBHs observed no change in some clients for whom they were carrying out rituals, leading them to believe that such clients were experiencing problems that AMHPs could help address. This was a crucial realization that facilitated agreement on the referral process. For example, one FBH commented on how he distinguished mental illness from possession:

The differentiation in this is that when the evil person is possessed, overall his problems start reducing when he starts to do our holy rituals … in the case of mental illness, how ever many holy rituals we try to do, there is no improvement. So we realize that this person is suffering from mental illness. (ID 10, FBH)

Redefining the roles of allopathic mental health practitioners within the collaboration

After trust was established between AMHPs and FBHs, additional elements had to be put in place to ensure both systems benefitted from collaboration. One example of an important component was cross-referral. In practice, this meant AMHPs stepped away from their usual routines/practices by conducting a needs assessment of the client and breaking down the problems clients presented with, in order to take into account both spiritual and medical needs. This also meant that AMHPs learned to accept that other approaches and practices outside of the allopathic system might be helpful for clients.

Essentially, a client coming to the dargah with problems would usually first consult a FBH for spiritual rituals. If the FBH sensed that their rituals were not having the intended effect or noticed that the problems were more severe, the FBH’s role was to refer the client, if they wished, to an AMHP in the dargah. Then, psychotropic medication, if required, was prescribed by a psychiatrist, and basic counselling (e.g., psychoeducation, active listening, problem-solving) was provided by a social worker or psychologist. Allopathic care was thus provided simultaneously to the client completing his or her rituals, which spanned approximately 40 days. An important motivation for AMHPs to cross-refer clients back to FBHs was to ensure that the FBH livelihood remained unharmed.

In this project, we also ensure that all the clients … coming to treatment at this dargah, they must be referred by the FBHs, so that gives reassurance that they will not lose their income or their livelihood … so we ensure that clients are mostly referred by FBHs, and after the consultation with AMHPs, they are sent back to the FBH, so FBHs do all the follow-up activity. (ID 15, AMHP)

Bolstering the roles of FBHs within the collaboration

FBH were considered “gatekeepers of care” within the DDP framework, as they were often the first point of contact and had the option to refer clients to allopathic mental health services (or not). In this way, FBH were able to detect a segment of the population that might otherwise go undetected by the allopathic health system. In addition to providing faith-based rituals, FBHs took on new roles in DDP, becoming responsible for several mental-health-related tasks, such as identification, referral, and follow-up:

Now the majority of FBHs are identifying the patient, referring the patient, following-up the patient, so this is the positive aspect … FBHs do all the follow-up activity and other things … so equality and liaison between doctors and FBHs. That is the main thing. (ID 15, AMHP)

The quantitative data show that over a 5-year period (2008–2013) FBHs referred 57.9% of the 3,172 clients receiving care from the DDP. The remaining clients were referred by other clients (8.8%), self-referrals (19.1%), by other health professionals (2%), and by others (12.1%; includes teachers, family members, neighbours, and community members).

The user population at the DDP

Demographic and clinical characteristics of service users

Characteristics of the 3,172 DDP clients are summarized in Table 1. Results revealed that both sexes were equally as likely to use DDP services. The mean age of clients was 34.95 (SD = 14.63). The majority of the clients were married (73.9%), were living with their families (95.5%), and had completed primary school (48%). Nearly a third of the sample was illiterate (30.5%). There were equal numbers of clients with Hindu and Muslim backgrounds accessing care at DDP, and there were no major differences between clients coming from rural and urban settings. Males were overrepresented in the sample of users selected for the qualitative interviews (n = 3), however all other demographic characteristics were consistent with the broader client sample (n = 3,172).

Table 1.

Sociodemographic and clinical characteristics of DDP clients (N = 3172)

Characteristic	Mean	SD	N	%
Sex (males)			1570	49.6
Age	34.95	14.63
Marital status
Single			787	25
Married			2330	73.9
Divorced			12	0.4
Other			20	0.6
Education level completed
Completed primary school			1531	48.3
Completed secondary school			458	14.4
Completed higher secondary school			99	3.1
Completed graduate school			69	2.2
Completed postgraduate school			14	0.4
Other			2	0.1
Illiterate			967	30.5
Religion
Hindu			1575	49.7
Muslim			1585	50.0
Other			8	0.3
Living situation
Family (immediate			3026	95.4
Extended family only			3	0.1
Friends			1	0.0
Rural			1414	44.6
Employed			237	7.5
Diagnosis (using ICD-10 criteria)
Organic, including symptomatic, mental disorders (F00–F09)			181	5.7
Mental and behavioural disorders due to psychoactive substance use (F10–F19)			22	0.7
Schizophrenia, schizotypal and delusional disorders (F20–F29)			872	27.5
Mood (affective) disorders (F30–F39)			769	24.2
Neurotic, stress-related, and somatoform disorders (F40–F48)			769	24.2
Behavioural syndromes associated with physiological disturbances and physical factors (F50–F59)			185	5.8
Disorders of adult personality and behaviour (F60–F69)			29	0.9
Mental retardation (F70–F79)			99	3.1
Disorders of psychological development (F80–F89)			2	0.1
Behavioural and emotional disorders with onset usually occurring in childhood and adolescents (F90–F98)			6	0.2
Unspecified mental disorder (F99)			218	6.9
Duration of illness prior to care (in months)	55.25	69.38
Age of onset	30.91	14.47
Client’s belief about origin of their mental health problems
Illness (related to the medical model)			1634	51.5
Supernatural causes			1530	48.2

Once clients had consultations with the AMHPs, their diagnosis was documented in the DDP database according to ICD-10 diagnostic criteria (Table 1). The most common diagnoses were schizophrenia and schizoaffective disorders (27.5%); mood disorders (24.2%); and neurotic, stress-related, and somatoform disorders (24.2%). The mean age of onset was 30.91 (SD = 14.47). This was not, however, the way in which the FBHs detected mental health problems, which was guided more by the clients’ response to rituals and the nature of the problems they described.

Help-seeking trajectories

The quantitative data reveal that the mean duration of illness prior to seeking any form of care was 55.25 months (4.6 years; SD = 69.38). However, during interviews clients reported that they took much longer before seeking care; most interviewees claimed that they used services perceived to be ineffective or that led to limited improvement for, on average, 7–10 years before accessing services at the DDP. When first seeking care at the DDP, nearly half of clients (n = 1,545, 49%) initially received consultations from the FBH compared to 12% (n = 381) who received a consultation from an AMHP first, and 38% (n = 1,996) who received consultations from both types of practitioners during their first visit (spiritual and allopathic care provided by both FBHs and AMHPs).

Many clients had histories of service use within both the allopathic and faith-based systems, approaching care-seeking in a “trial and error” fashion. These trajectories illustrated complex care pathways (continuously seeking and receiving care from different types of services without any perceived improvement). Other clients were able to come directly for care at the DDP (often due to a referral from a relative or a FBH), bypassing other services:

He used to read the newspaper … and he read about these symptoms he thought it could be mental illness. So then he went to medical doctor … and he got a sonography … and he said that … “you don’t have any problems, I’ll give you medicines,” but the medicines did not work. So second time, for his sonography, nothing was detected. It was the third time he got a sonography when the doctor told him, “you’ll have to go to a psychiatrist.” So he referred him to a private psychiatrist who charged him a bomb, exorbitant money … and he continued with the medications and was fine. But then he felt not fine again so … he tried a psychiatrist in Ahmedabad, there was no improvement. Then he went to … another private psychiatrist … [There] He improved a lot and then he stopped taking medicines … So then he went to another doctor but there was no improvement. (ID 4, U)

The cost incurred from faith-based and medical services during these previous help-seeking trajectories was one of the most frequently cited themes across interviews, and the financial burden that treatment costs posed to carers and clients was evident. Costs of care included travel costs to health facilities, consultation fees, and medication costs, and often led carers and users to access alternative services or cease treatment, causing relapse and, subsequently, additional costs. Some clients and carers spent most of their money on medication prescribed by allopathic doctors: “I have visited all the doctors, and I’ve spent more than 300,000–400,000 [rupees] only on medicines, since 2003” (ID 4, U). Others spent substantial amounts of money (relative to their income) on faith-based solutions, incurring consultation costs of up to 10,000 rupees for FBH alone. Some carers did not have enough money for treatment costs, leading them to borrow money from their social networks in order to pay for treatment for their relatives.

Reasons and motivations to attend DDP

Reasons and motivations of both clients and carers to attend DDP were primarily attributed to the free cost of the programme, attitudes of DDP staff (friendly, warm, cooperative), and feelings that clients were on the path to recovery while at DDP, compared to experiences with previous services:

When I used to go to a private doctor he would explain me the problem and prescribe medicines for years. Whereas when I visit the DDP they listen to my problem and try to give me a solution, which is helping me a lot. (ID 2, U)

Another implicit reason for attending the DDP was the positive interactions and alliances built with DDP staff. Clients stated that DDP staff were cooperative and positive and took the time to understand their problems. One client mentioned he was very comfortable visiting the DDP, and that staff treated him like a “normal human being,” while another client appreciated the problem-solving focus and the help he received in reviewing his thought patterns.

Experiences with the DDP

Both clients and carers stated that they were satisfied with the programme as a result of direct benefits (e.g., clients’ health improvement) or indirect benefits of the programme (e.g., restored livelihood). Specific reasons for satisfaction included the free care, and the perceived improvements carers saw in their relatives and clients saw in themselves, which included improved daily functioning and reduced symptoms:

The changes I have seen in my father have been that he has regularized his daily routine, he does not roam around, he is not blabbering, he is quiet, he eats regularly, and he goes to sleep regularly. I have seen phenomenal changes in my father. (ID 7, C)

When carers spoke about improvement, it was often related to the positive effect they perceived medication to have had on their family members.

Clients corroborated these improvements, feeling that they had progressed since consulting AMHPs and FBHs in the DDP. One client talked about the benefits of the basic counselling he received at the DDP, and how it helped him in distinguishing between helpful and unhelpful thoughts, which he had been unable to do before:

Now I can control thoughts—earlier I couldn’t … After counselling [at DDP] I realized what are good thoughts and what are bad thoughts. So when I get bad thoughts, I start controlling my thoughts, earlier I could not do that. (ID 2, U)

Clients attributed their improvement to a combination of the rituals they completed with the FBHs, and the medication and basic counselling they received from the AMHPs. FBHs also observed that their clients improved after receiving care at the DDP, compared with previously accessed services: “There are people who have availed treatment outside and have come to dargah … and when they’ve started using DDP I have seen them getting cured and improving” (ID 10, FBH).

In this context, it is important to note that when FBHs talked about improvement, they often referred to the effect of medications after referral to the AMHPs.

Livelihood restoration and impact on poverty levels

Across both FBHs and AMHPs, and both clients and carers, the most frequently cited benefit of accessing care from the DDP was the restoration of livelihood opportunities and freeing up financial resources. Restored livelihood consisted of new employment opportunities or returning to former employment after receiving treatment (for clients and carers), and continued economic opportunities. Clients and carers were also able to allocate money and time previously spent on seeking treatment to other areas of life (e.g., family, education).

It [the DDP] has helped me a lot … it has given me a more peaceful life … If I would have not got my daughter treated, I would have committed suicide … Thanks to DDP I am able to take care of my family. (ID 8, C)

Providing free care and medications enabled the programme to reach out to those living in poverty that needed care the most and might not be able to access care otherwise:

I’ve spent lakhs [hundreds of thousands] of rupees, I’m a very poor man, I don’t have money. But since last 2 years, DDP has given me such happiness that at last I can earn and give money in the house, because earlier whenever I used to earn, my money used to go into medicines. (ID 5, C)

It is important to note that the region where the DDP is situated has a paucity of services to cater to mental health problems, and is in a rural part of the state, requiring substantial travel to get to the major cities with mental health services. While there are primary health clinics situated nearby the dargah, staff at these clinics is not trained in recognition or treatment of mental health problems. Thus, seeking care at the DDP both alleviated the financial burden attributed to treatment and reduced transport costs associated with accessing care.

Viewing the client holistically

One aspect which could have contributed to positive views of the DDP is the fact that the programme adopted a more holistic approach to care by taking into account a client’s beliefs and needs without forcing a choice of accessing one system of care over the other. AMHPs working for the DDP became cognizant that a holistic approach benefitted clients more than addressing spiritual or medical needs in isolation:

I had a perception that … people get cured only by getting medicines. But once I started working here I realized that it was not only the medicines working, but it is the faith and support of others which is making it work. (ID 13, AMHP)

FBHs expressed that Dava and Dua need to go hand in hand in order to optimally aid the client in recovery: “Both of these things work, hand in hand, and people start getting cured … when the divine power mixes with anything, even medicines, it becomes effective for the people who come here” (ID 6, FBH).

Discussion

In India’s pluralistic health care context, the majority of service users access services from multiple systems, creating a need to develop methods of collaboration between local systems to provide integrated care. This study explored an example of sustained collaboration for mental health care between allopathic and faith-based systems in India to examine how the collaboration was realized, the user population accessing services provided by the collaboration, and stakeholders’ experiences of it.

Our findings reveal several mechanisms important for such collaboration, namely, building trust, respect, and rapport; highlighting complementary aspects of both systems; mutual referral; cultivating openness and mutual learning; consistent dialogue and information exchange; identifying shared goals; and redefining the roles of both AMHPs and FBHs. Other scholars have outlined similar components for successful collaboration for other public health priorities (e.g., HIV/AIDS, tuberculosis; e.g., Campbell-Hall et al., 2010; Kayombo et al., 2007; King & Balaba, 2009; King & Homsy, 1997). Building trust, mutual respect, and rapport emerged as an important component throughout the development of the programme and occurred on both professional and systemic levels. It is important to address the mistrust and apprehension of professionals in both systems before a functioning partnership can be established (Burnett et al., 1999). In the DDP case, trust was built through gradual and persistent dialogue (through joint client consultations, regular meetings, jointly led community activities to raise awareness) initiated by the AMHPs, which is in line with previous efforts (Kayombo et al., 2007). Open dialogue earned trust from key FBHs and trustees of the dargah who subsequently conveyed the vision of working with AMHPs to other FBHs. Additionally, rapport building occurred through symbolic yet meaningful processes in the partnership, such as AMHPs and FBHs sitting on the floor together during consultations to show or demonstrate that there is an equal status between practitioners.

Systematic and gradual training sessions, including refresher training, enabled both faith-based and medical practitioners to learn about the other’s practices and approaches. Previous research shows that FBHs who were regularly supported after training sustained their “new” roles within the collaboration longer and more intensively compared to those who only participated in basic training (Homsy, King, Balaba, & Kabatesi, 2004). FBHs are well-respected community leaders, easily accessible for persons with limited financial resources, and thus can reach out to a population that largely goes undetected by formal allopathic services, especially in underserved settings (Kayombo et al., 2007; Padmavati et al., 2005; Raguram et al., 2002). It is less clear, however, to what extent AMHPs were able to adopt views from other local systems of healing, as much of the process of the DDP collaboration was driven by AMHPs. Our findings suggest that AMHPs were reluctant at first to equalize their status with that of FBHs, but increasingly grasped the value of FBH practices over time, particularly when observing the positive effects that the FBH had on clients’ overall wellbeing.

In line with similar research conducted in India (Kishore et al., 2011; Padmavati et al., 2005), we found that a larger proportion of service users from both urban and rural settings first sought care through the faith-based system, in contrast to a previous study that found that a larger proportion of clients sought help first from psychiatrists compared to FBHs (Chadda et al., 2001). We also found a substantial number of Hindu clients seeking care at the DDP, which was unexpected as the dargah is a Muslim religious site and performs different rituals than Hindu sites. However, previous research suggests that the religious orientation of places of worship may be less important than the relief such places provide from symptoms or distress (Campion & Bhugra, 1997; Padmavati et al., 2005; Pakaslahti, 2009; Quack, 2012).

Although stakeholders interviewed had different interests and roles, the majority were positive about their experiences with the DDP. Clients and carers attributed their attendance at the DDP to positive staff interactions, perceived improvement (compared to previously accessed services), and the free cost of treatment, which alleviated financial burden and allowed for more space and time to concentrate on employment and providing for their families. FBHs were also able to maintain their income through cross-referrals within the DDP. This could partially explain the reason that FBHs overcame their initial resistance to collaborating with AMHPs, as resistance from FBHs observed in the past in other countries stemmed from fear of losing their livelihood (Kayombo et al., 2007).

Finally, one strength of the DDP was the ability of both AMHPs and FBHs to see clients holistically, in that clients were not required to choose between explanatory models of illness that they may have held; in this way, the programme approach reflected local needs (Davar, 2014). The DDP promoted interaction and treatment from both systems, allowing for a more comprehensive care approach. This required practitioners in both systems to be flexible and see the client in the context of his or her social, spiritual, economic, and political environment and needs (Campbell-Hall et al., 2010; Kleinman, Eisenberg, & Good, 1978). The DDP’s inclusive approach to mental health aligns with the view of other scholars that approaches to distress and healing are more likely to be perceived as helpful and positive when they align with perspectives and conceptualizations of the local community (Campbell & Burgess, 2012).

In terms of the configurations of collaboration discussed above (Campbell-Hall et al., 2010; Freeman & Motsei, 1992), the DDP fits the category of coordination/collaboration, but incorporates elements from the other two configurations. Although FBHs are positioned as gatekeepers of care at the community level, the two systems remain autonomous in many respects, with the exception of mutual referral processes. It remains unknown, however, under what conditions and at what frequencies these mutual processes occur within the DDP. Although the DDP does not necessarily represent an ideal framework for collaboration, it does exemplify the possibility of working jointly towards improving outcomes for clients over a sustained period of time. Ideally, as Campbell-Hall et al. (2010) discuss, the collaboration would be more equitable, involving more mutual learning opportunities, particularly for AMHPs to accept and learn about faith-based practices. Indeed, as Campbell-Hall and colleagues articulate, the challenge of collaboration between two autonomous systems appears to be avoiding the imposition of one system over the other. Quack (2012) states that many collaborations are one-sided and are better referred to as “utilization.” Indeed, the DDP does “utilize” existing community resources and is more heavily influenced by the biomedical perspective. The risk of a one-sided collaboration is that the faith-based sector may be forced to transform into a version of the allopathic system (Quack, 2012). One suggestion for avoiding this is to acknowledge this risk, and mitigate it by continuously creating opportunities to learn about one another’s practices, reiterating the shared goal of the two systems to benefit the client and contribute to wellbeing and ensuring that tasks and responsibilities are mutually reinforcing rather than one-sided. That being said, this study documents the existence of a collaboration heading in the right direction towards forging a mutually beneficial partnership for both systems. The DDP, although a small-scale, local program, is more than a pilot project, as FBHs and AMHPs continue to work together under the framework of the program even without external support or funding. There is clear commitment from local stakeholders, evident in the fact that 2016 is the DDP’s seventh year of operation. The positive perceptions of stakeholders and sustained nature of the DDP have policy implications as they showcase the personal and community-level benefits of investing effort in forging local collaborations that align with community needs and perspectives (Campbell & Burgess, 2012; Sarin & Jain, 2013). While the importance of community-based approaches to mental health care has been articulated in India’s national mental health policy as well as more broadly in the global mental health arena, further emphasis on community engagement and steps towards initiating such processes are still needed.

Future research could delve deeper into the barriers to establishing and sustaining collaboration and delineate potential solutions to these challenges. Moreover, clear outcome measures could help to more concretely assess the impact of the DDP on the lives of clients and carers. This paper demonstrates the need for structured epidemiological and anthropological research to better understand the interactions between different stakeholders and how these interactions change over time. Third, implementation and local adaptation of the DDP in other contexts are needed. This should include close collaboration with communities to grasp local strategies and support networks in order to understand future routes to and platforms for collaboration, as well as an evaluation of the implementation process.

Limitations

This study had several limitations. First, there was potentially a social desirability bias in the interviews, as challenges or negative aspects of the programme were very rarely mentioned, with the exception of initial apprehension towards the collaboration. Second, we employed a small sample size for the interviews based on convenience sampling, and thus the results are not easily generalizable to other contexts, although the aim of this study was not to achieve generalizability to other contexts given the specificity of this particular healing site and partnership (Raguram et al., 2002). Rather, the aim was to understand linkages between the two local systems from the perspective of providers. Third, we retrospectively looked at the client database for quantitative analysis, which did not include any formal outcome measures or rating scales administered to clients and carers, and therefore were reliant on subjective reports of improvement. The lack of evaluations coupled with uncertainty arising from the perceived unscientific or exploitative nature of faith-healing (Patel, 2011) makes it difficult to fully ascertain the benefits of the programme (King & Homsy, 1997).

Conclusion

Pluralism views all sectors as coexisting parts of a connected system in which clients concurrently or continuously use different types of care (Fink, 1990; Homsy et al., 2004; Kleinman, 1980). This pluralism can be seen as necessary in a country with a large treatment gap and limited resources, particularly in the biomedical system. Widespread use of multiple systems for mental health care has forced the allopathic system to find alternative configurations of care that utilize existing financial and human resources, such as collaboration with other local systems of healing (King & Homsy, 1997). Holistic care may be particularly beneficial for chronic illnesses, including mental illness, as these often require ongoing care from multiple practitioners and levels of a system. Although the allopathic and faith-based systems in India can and do often function independently, when working together, they can additionally promote a shared responsibility for improving client care, respect the client’s wish for treatment from both systems, and provide a more holistic approach to care for clients and families (Jain & Jadhav, 2009; King & Balaba, 2009). That being said, collaboration between systems of care is not a simple task. Findings from the Dava Dua Programme suggest that gradual cultivation of trust, respect, understanding, and dialogue is essential, as are community participation and a solid understanding of the local culture and context of help-seeking and healing (Campbell & Burgess, 2012). Continuous and open dialogue is crucial in alleviating mistrust, building confidence, and sharing knowledge, and may lead to a more coordinated approach for managing mental illness (and other diseases; Kayombo et al., 2007). Thus, allopathic and faith-based systems are not entirely incompatible, and if there is acceptance of both practices, collaboration can emphasize the complementary aspects of both (King & Homsy, 1997). Having different paradigms of beliefs and practices between systems should not exclude the possibility of collaboration. Instead, working towards a system of co-operation between two independent systems while fostering respect, mutual learning, and trust, appears to be one way forward to providing much needed care in a country with limited financial and human resources in the field of mental health.

Footnotes

Acknowledgements

We are grateful to the clients and their family members for participating in the interviews, as well as to staff working in the Dava Dua Programme who participated in this study. We also would like to thank Thijs den Hertog and Dr. Soumitra Pathare for their helpful comments on earlier versions of this paper.

The authors would like to specifically thank the mujavars, service users, and carers who agreed to speak with us and share their perspectives. Continued support from the state government of Gujarat, India is gratefully acknowledged. The authors would like to thank Soumitra Pathare, Sarah Cummings, Sorana Iancu, Wim Brandsma, and Thijs den Hertog for comments on earlier drafts of this article, and the Dava Dua team for their efforts in data collection.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Note

Laura Shields (MSc, PhD) is a project manager and research associate at the Trimbos Institute (Netherlands Institute for Mental Health and Addiction). Her main area of work is in health services research with a particular focus on reform of mental health services in low- and middle-income countries. Her published works focus on mental health services development, policy development and implementation, community-based mental health care, and mental health and human rights.

Ajay Chauhan (MD, DPM) is the Medical Superintendent of the Hospital for Mental Health Ahmedabad and the current Programme Officer for Mental Health for the Department of Health and Family Welfare, Government of Gujarat. His work focuses on cultural psychiatry and mental health, human rights, and law in India.

Ravindra Bakre (MD, DPM) is a retired state mental health programme officer for the government of Gujarat, India, and an Emeritus Professor in Psychiatry at the Gujarat Forensic University. He holds interests in community and forensic psychiatry and has served as a consultant for a number of mental health system assessments in the state of Gujarat and led a series of pilot projects in community mental health in the state.

Milesh Hamlai is a carer and the founder of Altruist, a nonprofit organization based in Ahmedabad, Gujarat, which offers support and services to both people with mental health problems and their carers, and also raises awareness in the community about mental health.

Durwin Lynch (MSc) is a PhD candidate at VU University Amsterdam in the Netherlands with a background in innovation studies and health-related policy-making. His main research is focused on linking the knowledge and expertise of citizens (as end users) with developments in science, technology, and policy-making. He is particularly interested in methodologies that enable citizens to take an active role in solving complex problems related to sustainability and health.

Joske Bunders (MSc, PhD) is Professor of the Faculty of Biology and Society at the VU University Amsterdam in the Netherlands. Her specific field of interest is the linking of knowledge and expertise of end users (e.g., small-scale farmers or patients) with developments in modern science and national and international policy. Dr. Bunders has published widely in the area of biotechnology and the role of users in shaping the innovation process. She has also conducted research on the development of methodology to stimulate and facilitate interactive and transdisciplinary processes of problem-solving.

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