Psychology in Action
Mental health in Nepal: The voices of Koshish
By Matrika Devkota
Matrika Devkota is a mental health advocate who lives in Kathmandu, Nepal. After experiencing the discriminatory attitudes toward mental illness and the lack of mental health resources in his country, Matrika founded Koshish as a "self help” organization where those with mental disorders are given a voice and an opportunity to advocate on their own behalf.
Nepal is a country full of different cultures and traditions; but when it comes to mental illness, each of these cultures shares the same concepts. In Nepal, most of the people think that suffering from mental illness is the same as being mad, becoming unfit to remain in society and the family due to loss of control over self, or even being possessed by a holy spirit or a black magic. Individuals with severe mental disorders, as well as their family members, are targets of stigma and discrimination to the point where they hesitate to come forward for appropriate treatment. Even patients with neurotic disorders do not like to consult mental health professionals because of the stigma of mental disease. Although Nepal's constitution regards health as a basic human right, the system’s definition of health and its exclusion of psychological care has led to a faulty understanding of this right, and the Nepali Health Care System neglects this aspect of people’s health care treatments.
In terms of financing, less than 1 percent of health care expenditures by the government are directed toward mental health. Although as yet there is no separate mental health legislation, a final draft of mental health legislation has been prepared and under review in the ministry of health. The law in Nepal continues to define mental illness as a madness. In the civil code, the legal definition of mental illness is not clarified, but the language of the legislation refers to someone with a broken mind. As noted above, this attitude is reflected in everyday practice.
The number of mental health care professionals in Nepal is low. According to a report by the World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS 2006), the breakdown according to profession is:
32 psychiatrists (0.129 per 100,000 population),
6 psychologists (0.024 per 100,000 population),
16 other medical doctors, unspecialized in psychiatry (0.0645 per 100,000 population),
68 nurses (0.274 per 100,000 population),
No social workers, No occupational therapists.
Despite its challenges, attention to mental health in Nepal is increasing. The country has a national mental health policy, and human resource development is gradually taking place. In addition, there is a network within the general health service system where mental health can be integrated. There is a gradual increase in awareness of mental health in the general population, and the number of people seeking treatment in the mental health institution has increased. Psychotropic drugs are widely available, and are included up to the primary health center in the "essential drug" list.
Although increased awareness of mental health and mental disorders is to be welcomed, there are important challenges in access to mental health care in Nepal. These include:
Lack of adequate mental health professionals and treatment facilities. There is only one mental health hospital in the country, and mental health services are not easily available in rural and remote areas.
Mental health infrastructure is poor and human resources are not sufficient to meet the need. At present, most psychiatric wards are staffed and run by general nursing staff without specialized training in mental health or disorder.
Governmental structures to address mental health are not yet in place. Although legislation is planned, there is presently no division for mental health under the Ministry of Health, and there is not an adequate budget for mental health services.
There are no consumer or professional organizations that advocate for mental health issues.
Given the lack of services and medical infrastructure, non-governmental organizations (NGOs) have been working to provide mental health and other services. One such organization is Koshish Nepal.
Koshish is a nongovernmental organization registered in the District of Kathmandu, with the approval of Nepal Social Welfare Council in 2008. The organization evolved from the commitment of a few people who used mental health services in Nepal and recognized the need for improved systems and reduced stigma. The word "koshish" means "making an effort" in Nepalese, and this new organization decided to make an effort to mainstream mental health and psychosocial disability. These efforts began in 2004 by providing support for homeless persons with mental illness. Koshish is a pioneer mental health self-help organization working with a rights-based perspective for persons with mental disability in Nepal. The organization is lobbying to get public and policy attention for persons with mental disability and has been involved in the rehabilitation of dozens of people affected by mental illness. One case story, repeated here with permission of those involved, will help illustrate Koshish’s activities.
Seti’s reintegration in the family is one of the successful case stories. Seti is a 43-year-old woman who lives in the western part of Nepal. Three years ago, her husband — who worked as an agent for foreign companies seeking employees — passed away, and Seti entered a prolonged period of mental disorder. She traveled to Kathmandu, stayed at the Pashupatinath temple, and then began living out on the streets. Her family tried to find her in every possible way, but they failed. Seti lived in the street for three months. She had no knowledge of herself or her family. People called her Boulahi, meaning "insane woman," and Seti faced an overwhelming amount of cruel behavior from even the most respected people who saw her.
Seti was rescued from the street in October 2010 with the support of police. With the support of Koshish and police, she was taken to a private rehabilitation center. For more than one month, Seti still suffered from her mental disarray. She didn’t know who she was and didn't like to wear clothes or sandals. Over the next months, her health showed gradual improvement. She regained her memories, and her illusions and hallucinations were gone. She realized the importance of taking medicine and started behaving normally. Seti shared information about her family, and Koshish was able to find her relatives. Seti's son came to take her home and was given consultations on his mother’s care so that possible relapse could be avoided.
This story, and others like it, are important to illustrate in Nepal and to the local population. Please visit the website to learn more.