Thursday, 26 November 2015

A Transcendental Indian Adventure (3) A Living-Learning Experience like no other

When we started the British LLEs at Commonwork organic farm and study centre in 1995, an important part of the bonding ritual for the staff was to meet in Sevenoaks Sainsbury’s to do the shopping. We would travel from wherever we worked and gather, at about 5pm on the day before the workshop started, in the coffee shop. Then we would start in earnest and, after about two hours, end up heaving around four or five shopping trolleys containing all the meals, snacks, drinks, and everything else we were going to need for the three days in our Kentish therapeutic bubble. Even in those days – now between ten and twenty years ago – the bill at the till would come to something between seven and nine hundred pounds for about twenty five people. More recently, we have become a bit lazy – and Sue has done all the shopping for us with Tesco Online. Although it’s a lot more efficient, and tightly budgeted (it is now less than six hundred pounds), we have lost something in the process: we also used to treat ourselves to a meal out at the Chiddingstone Castle once we had unpacked it all – now we just cook something simple for our pre-workshop evening meal, in the modernised kitchen at Bore Place (the Jacobean manor house we’re based in at Commonwork), and have our pre-workshop staff meeting. For our Indian Adventure, the food was going to be a different experience altogether – and in comfortable city-lifestyle Bangalore, we had no inkling of just what that was to mean…

Not like Sainsburys
Getting it in the car
All four of us – Anando, Jan, Sandra and myself – turned up at a large supermarket in the city, in a car already stuffed with luggage to take the road 145km north to the women’s Training Centre near Penukonda. Not quite the same as Sainsbury’s in Sevenoaks! But as the main basis of a good proportion of Indian food is dry stuff – it was weighed out into huge bags of rice, lentils and chick peas. That, plus a bag with a couple of fish and a bag with a couple of chopped up chickens, and numerous packets of masala and spices, made up most of the substantial cooking we were to do. We decided to get the fresh vegetables and fruit from the market in Penukonda after we got there, so with a few goodies like chocolate bars, white bread, biscuits and jams, we manged to squeeze it all into the car quite easily: excluding the wine we had with meals it came to 17000 Rupees – about £170 – less than a third of what we spend in the UK. A final stop for the wine, then two hours and good dual carriageway past the new airport, and we were there.

 The dual carriageway gave us a false sense of security – and it was almost like an augur as we came off it and onto the village road and approached the training centre: no longer just animals, people and vehicles – but a bright green bush, the size of a small car, travelling towards us like something from another world. As it passed, we saw there was a wiry and athletic old man beneath the bush (which was a mass of freshly cut sugar cane), on a small scooter. But another world, it certainly was.
Arriving at the Training Centre

In India, we had become used to some of our normal facilities being intermittent or only available in some places – like air conditioning, broadband, mobile phone signal and hot running water, and to have short interruptions to electricity. But this was to test us much further – no chance of internet or phone signal unless you drove into Penukonda village (about 3km away), no hot water unless you boil it yourself over a log fire, no running water at all for hours at a time (seemingly something to do with the electric pump to the water tower, which also explained why water was pouring over the side and flooding the muddy path between the different buildings), a little bit of gas for cooking – but most of it needing to be done on smoky indoor log fires, and very intermittent electricity. And this is to say nothing about our safety being compromised by the voracious insects, snakes and other aggressive wildlife we fantasied about, and imagined we were hearing, at night. Then there are the termites, which apparently can eat all the wood in a door in about three months – leaving just the paint holding it together, and mostly dust where the wood was. Anando found this out when we tried to go into one of the dormitory blocks through the back door, half of which immediately disintegrated into powder as he pulled on the handle. Hence most doors in the place were metal – but the climate had taken its toll there too, with many of them rusted and either difficult or impossible to close and lock. Then there were the sliding metal grills, slightly rusty and stiff from lack of regular use, between the different sections of the training centre - mainly to isolate the kitchen and dining area from the outside. What were they for, and why were there so many of them?
The cooker

The washing-up room

The answer turned out to be the biggest animal threat that we encountered: a species much closer to our own than any of the ones we feared – monkeys. At first they seemed quite cute, a family of four sitting on top of the roof, watching us come and go as we unloaded our goodies from the supermarket. Then we returned after going to somewhere else on the site and noticed something wrong – where had we put all those pappadums? Didn’t we have five loaves, not three? And what were those bits of half-eaten banana under the table? Far from watching us with benign and friendly interest, they had been sizing up what we were putting where, and how they could half-inch as much of it as possible. And now they were not just a sweet little nuclear family, but an extended family – probably a whole village of monkeys – coming at us from all angles in the trees all around. The most audacious theft was when I was carrying half a loaf of bread to the kitchen to make myself some breakfast, slightly blurry with virus and fever I’d contracted, and suddenly something swooped down from the tree by the entrance grille, I felt little finders grapple with my hand - and before I knew what was happening, the half loaf was disappearing up a tree with several of the cheeky monkeys grinning down at me. So much for my curry-free breakfast of toast and marmalade!

The enemy
Before long, the fight against the food thieves became an all-out war – and we employed innocent children, fireworks and guns to fight our cause. One of the participant members of the LLE had bought along her two young girls, who delighted in being appointed as the monkey patrol when we were in our groups and community meetings: they would keep watch over all the food in the kitchen and dining room, and would chase off the monkeys however they could. We soon used up a box of the fireworks – loud bangers – which kept them away for an hour or so, so we sent Anando (aka Dobby) into Penukonda to buy more. But as matters worsened, Azad – the young farmer from Kracadawna who was a member of the community – borrowed an air gun to send them scurrying more effectively, with a few harmless but painful shots in the bum for various persistent primates. Some of the more rurally-accustomed members felt that a real gun, with real bullets, would be more in order – but thankfully we didn’t go that far. But we never won – they kept coming and going - but at least they didn’t get much more food.

After we had finished unloading the food and luggage, we had our traditional pre-workshop staff meeting, going through the application forms of everybody who was expected to turn up the next day, before going to Chandra Kanjilal’s house for dinner.

Chandra is a retired woman of extraordinary energy and experience, who had set up the training centre (link to Google Maps, earth view here) about twenty five years ago, with German international development funding – and has lived there with her daughter (an NHI employee, sometimes her son-in-law (who works away), an elderly dog, a young dog and four playful puppies ever since. Until the development funding methods and perceived needs changed about seven years ago, she ran numerous courses – for dozens of people at a time for extended stays at the training centre - to help empower local rural women, from all the surrounding areas. The stories she told us of how utterly disempowered they were seemed a far cry from what we think of as ‘disempowement’ in the UK. For example, how women were exploited by money lenders, suffered domestic abuse, sexual abuse and, if they were widowed or divorced or had mental heath problems, were terribly exposed to the likelihood of severe abuse, exploitation and ridicule. For women,the situation was, and to some extent still is, inconceivably awful for those if us  living comfortably in the west: although the enforcement of dowry payments is no longer legal, it still happens - and the effect of this has been to make girl births in jeopardy of infanticide.

But the centre had been unused since the last of the courses, in 2008, and it was rather sad to see many photo boards in the training centre rooms, faded and decayed with age, showing the place full of life, action and energetic people doing emancipatory things together. So Chandra is very keen that it takes on a new lease of life as a venue for the LLE mental health training – which is hopefully also emancipatory, and in the service of empowering staff, and ultimately patients, in a way that is progressive, sustainable and powerful. Hence a potential win-win situation in her relationship with HNI.

The community room
The LLE itself ran to exactly the same timetable as it does in the UK and Italy – with community meetings at the beginning and end of each day, three small groups which meet five times including one to cook a meal for the whole community, and the rest of the ‘community time’ to be spent however the community decides. We had seventeen participants – including HNI staff, psychology postgraduate students, an engineer, a Greenpeace worker, Azad the young organic farmer from Kracadawna (see India blog #1), and four workers from the Mental Health Action Trust in Kerala (see India blog #4). We had a staff team of four – Jan, Sandra and I each conducting small groups, and Anando in the role of Dobby the House Elf – lighting the fires, running errands, helping with the cooking and generally knowing where everything is and how everything works (no mean feat for a workshop in this setting!).

Safiya shows us how to cook when it's our group's turn
 It all passed in a febrile blur for me – with an upper respiratory infection and fever throughout – but particularly notable moments included the production of fine Indian meals from such basic ingredients, over wood fires which smoked the kitchen out,without need for many words or instructions; washing up without running water; cheering as we let Chinese Lanterns float upwards into the night with a wish; monkey trouble; a chaotic group game called Mafia (an Indian version of what we call 'killer'), and dancing round the bonfire in the courtyard

Hanging out
Although Sandra, Jan and I started with severe reservations along the lines of ‘how can we presume to sit amongst these people and conduct groups in our normal way, when we have so little idea of what their lives are actually like and how almost everything about the culture works here?’, we were surprised how it all worked out. By the end, we had all made relationships which we felt sadness at ending – and heard remarkable and moving tales of how people manage their lives a
nd emotions. Most seemed to have got a lot out of it, as had we. An extraordinary, and unforgettable, experience.

Follow the LLE link on the right if you want to try it for yourself…

Tuesday, 24 November 2015

A Transcendental Indian Adventure (2) Buzzing around Bangalore

NIMHANS has always occupied a place in my mind somewhere near the Maudsley and Institute of Psychiatry, and my own psychiatric training - with fantastically high institutional standards but also a punishing and paranoid culture for the poor juniors who work there. I remember this in Oxford as ‘the dark shadow of the University Department’ and how nobody walking its corridors ever smiled – and we all lived in fear of getting the dreaded ‘green memo’ from the heart of Mordor (the professor’s office).

NIMHANS - the gardens b etween the inpatient wards
But today that prejudice was really changed into something much more up-to-date and positive when we were invited to visit the Department of Family Psychiatry and Rehabilitation. As we walked in, there was a profound sense of it being a good space: a relaxed feel, colonnades of green walkways festooned with flowers, yoga happening in the spacious grounds, large airy and light-filled rooms, and people who rushed up to us and introduced themselves – as well as a few lazy and random dogs lying around.

NIMHANS - Family Psychiatry and Rehabilitation
We sat in a multidisciplinary teaching session where they used OSCE (Observed Structural Clinical Examination) methods as a teaching technique rather than an examination – with a role play of a mother from a rural area coming to ask for help about her psychotic son. The observing students then had to first comment on what went well, then what could have been improved – ‘Pendleton’s Rules’ as I remember from my own GP training. In the following discussion we explained how TCs have developed and changed in the UK. Although they were quite familiar with the underlying concepts, it is interesting that they still thought that all TCs were residential – but perhaps not that surprising as the same misunderstanding was present in several medical members of the UK group that developed the NICE guideline for Borderline PD. But we then had a lively and passionate discussion about how TCs can offer hope to people who have not received what they need from the mainstream mental health services, help those who are dependent on services to take responsibility for themselves, and hold out the possibility of authentic ‘recovery’ – whatever that may mean!

We went to a well-westernised coffee bar (multi-coloured LCD lights, not much Indian food on the menu and loud pop music) for our debriefing, with a burger and salad lunch. Unfortunately this coffee bar, unlike the ‘CafĂ© Coffee Day’ chain that seems to be spreading everywhere, had no coffee, and then the waiter told us that tea was off as well. So we went off to our next encounter: Athma Shakti Vidyalaya, ASV.

ASV is one of the first TCs which joined the Royal College of Psychiatrists’ ‘Community of Communities’ quality network - soon after it was set up in 2002. I was the external peer reviewer for its first review in October 2003, and remember being bowled over by how the culture and ‘smell’ of a TC was as easily recognised in such an utterly different culture as urban India as it was in London, rural Cumbria or the Home Counties. But this time we were a threesome, and we only had an hour and a half with them. The first difference I noticed was how a rural village on the outskirts of Bangalore – surrounded by big fields, wandering cows and children playing cricket - had become a dense urban development filled with apartment blocks, a new Hindu temple, tarmac roads and buildings everywhere. Such is the pace of Bangalore’s expansion, Anando explained to us.
We started off with a rather formal-looking session with the three of us behind a desk, and serried ranks of staff and interns arranged in rows filling the rest of the room. However, we soon got into an interested exchange about what we had in common, how we differed – and what had changed since I was last there. Then it was time for community tea – and we had milky tea (without sugar, by special request), biscuits and Indian sweets. We were enthusiastically welcomed by the members of the community: they wanted us to stay, or come back, or even work there!
With the staff at ASV

The members come from far and wide – and have a wide range of reasons for being there: some see it as their home for ever, some use it as a secure base from which they go out and try to get on with life and come back if they need to, and some seemed to want to get away from the place as soon as possible. It was clear how some members felt listened to in a way that made others therapies they had received seem superficial, and not able to fully understand their situation and problems. Most people there had their places funded by their families – who sometimes pay for them to stay indefinitely. Because there is now quite a number of long-stayers, ASV is considering whether to build a new block in the middle of their yard to house them. Of course, a treatment like ASV is inaccessible to most people as they don’t have any money.

The entrance to Christ's - a 'corporate university'...
...which still has a lot of students.

We knew the next day, Wednesday, was going to be hard work – but we didn’t realise quite how much Anando had packed in. We started with a three and a half hours lecture/seminar session at Christ University – which is what they call a ‘Corporate University’, meaning that the fees are much higher than a state university, for which the students receive pretty much the same education, but have much more comfortable and modern buildings and facilities.

The room in which we did our presentations was kitted out with a smart stage and all the usual digital projection – but the audience all seemed to be sitting in rows of bright red comfortably upholstered armchairs. There must have been about eighty of them, all full with standing room only – mostly with postgraduate students from the psychology department. We left just after 8am to get there for a 9am start, and Anando was surprised at how gentle the traffic was – but he spoke too soon. When we got to about a mile from the university, we hit the big-time Bangalore gridlock: probably similar to most huge cities in low and middle income countries – but with the trademark Indian addition of holy cows dotted amongst the vehicles, sometimes even lying down amid the noisy chaos. We arrived about 10 minutes late, and everybody on the red seats went quiet and stood up for us: we reassured them that we came from a tradition of flattened or fluid hierarchies and they didn’t need to do that – then we did three of our normal prezi presentations: the English national PD programme, the history of British TCs since World War 2, and why the philosophy of greencare is good for your mental health (click each title for link to presentation).
Talking to the Christ's University students
We left plenty of time for questions and discussion – and there seemed to be a good understanding of what we were on about, and us and Anando made several useful contacts.

After a quick rice and curry lunch in the students refectory – a vast space with an even more vast number of students in it (there certainly seems to be enough people around to pay the fees for their study at a corporate university) – we were heading off to our next assignment: a team meeting with all the HNI staff in Anando’s parents’ front room. Interesting facts we learned about HNI include the geographical spread of their activities, that some of their staff are volunteers, and that the non-volunteers are all paid exactly the same.

After this, just before the sun set, we were led up to the top of a nearby building where there was an airy terrace with views across the city, a bar, food service area and a circle of twenty-odd chairs: lovely evening views across the city, a gentle breeze and music of the city traffic just warming up for the rush hour. Beep beep beeeeep honk honk vrooooom vroom.
Sunset above the hurly-burly
This was the setting for the three-phase evening event to which all the HNI stakeholders were invited – the Social Evening.  The first part was a reception and general mingle as everybody arrived – Sandra braved the streets of Bengaluru for the two minute walk from Anando’s parents’ house with a couple of others HNI, got lost and arrived just in time for the next part. Which was a group discussion on ‘where to with HNI?’, in a conversational competition with the orchestra of traffic - which had now finished warming up, and was playing at full tilt. Which made the discussion a little difficult, a problem the group tackled by bringing all the chairs together into concentric circles so everybody was within a few feet of each other. Some good ideas were batted about, with plenty of energy and passion – particularly from the families of community members. Then it was time to eat, again. And beautiful food, again, with plenty of people and good conversations with people from all sorts of different backgrounds (the orchestra was quieter by now). And so to bed – in preparation for the biggest adventure of all: the Penukopnda LLE…

Links to talks:

Saturday, 21 November 2015

A Transcendental Indian Adventure: (1) Biodynamic Greencare in Mysore

Although it doesn’t look far on the map of India, and we aimed to leave Bangalore at 7.30 to get to Vivek and Juli’s farm by lunchtime, it turned out to be a good deal less straightforward. We didn’t quite get our act together to be on the road by 7.30 - which gave time for a lot of motorbikes, and cars, and dogs chasing the cars, and scooters, and buses, and tractors, and herds of goats, and lorries, and autorickshaws, and cows, and dogs chasing cows to get ahead of us. Beep beep beep beeeep said the chaotic assemblage of flesh and metal – but Anando took the immersive chaos as a challenge, and showed remarkable dignity, respect and restraint - and barely muttered a single peep of frustration all the way to Kracadawna.

After spending in an extra hour escaping the city, the first stop was for breakfast, at a tribal art and culture centre  - then another two hours of humans, animals, vehicles and villages getting to Mysore. Which we went round 3 times. The first revolution was for an ATM and a bank, the second was searching for a wine shop amongst the lime green and candy-floss-pink houses of the back streets – including a few dead ends and diversions to get over the railway track, and the third for a loo, which turned into a coffee shop stop. And we didn’t even see the palace once.

As we got further and further from the city, the roads got narrower and narrower - although still with the added interest of swarms of motor bikes, very slow buses, occasional cows and tiny villages with big temples. Overtaking motor bikes usually involved an excursion into the opposite ditch, while oncoming traffic often landed us in our own ditch. Getting past wheezing buses was even more exciting. After about an hour and a half, we turned off into a long and winding – and deeply rutted – track across fields and farms, until we arrived at the kitchen, a separate building which is the hub of life at Kracadawna. Here's the link to see it on Google Maps, earth view:

Kracadawna landscape
Kracadawna is a 25 acre organic farm run by the Cariappa family, who – over thirty years - have turned it from a bare patch of land into the sort of eco-paradise loved by ageing hippies like Jan – and the new breed of ecowarriors like Anando and Shama. Our safety assessment had to include various contingencies unknown to the NHS risk police: marauding elephants whose transit corridor goes through the middle of the farm, and a man-eating tiger who has already eaten eleven villagers who can clear the 10-foot electric fence designed to deter the elephants, with eight foot to spare. Also a group of wild boars recently had a rave in the cornfield, and trampled it to the ground. They may be back for more, at any time! And then there were the mega-bugs, snakes, rats the size of cats, chattering monkeys and poisonous spiders.
Thirty years on...

However, despite the self-evident unacceptability of such a place for patient-safety-conscious mental health endeavours, it is not quite as life-threatening as the risk assessment might suggest. Nobody from the farm, either family or staff, has ever been hurt by the local wildlife, and the ecological management of the site means that it is becoming a ‘biodiversity hotspot’, and might become recognised and registered as such if the family commissions a formal survey. It is also a seen as a radical social structure, as they are separate from the local village community, use organic production methods unfamiliar to local people, and the farm employs people who could not work elsewhere. Juli explains how people employed here talk to her about their open and egalitarian style leads to a level of trust that allows the local village women to talk about things they would not say to anybody else. And the village men were suspicious of their organic neighbours for many years – for flouting the conventions of social hierarchy and acting in a fair and equal way to everybody; but once they got used to it, they too could establish a new and almost unknown level of trust with other men outside their immediate socio-economic circles.
Sandra, Kabir & Angeli,Anando, Azad, Juli, Rex, Vivek, Shama and Jan around the kitchen table at Kracadawna

Although it is not yet a fully functioning greencare TC programme, we were told a story of a weekend visit here by some Bangalore TC members, including an autistic boy and a couple of other members - which made more difference to how they relate to people around them and their enjoyment of life than years of special schooling, and rigorous programmes of behaviour management: though it wasn't without ruffling a few feathers back at home!

Meanwhile we got to work - and had several hours of detailed, honest and frank discussion of how Anando and Shama can make the TC model work in India, under the auspices of their 18-month old charitable organisation, Hank Nunn Institute, HNI. Although I have some antibodies to management concepts like these - a lot was about good governance, time management and focus. Interestingly, the charity laws in India seem even more strict than they are in the UK: with rigid rules about trustee board membership, and even more draconian procedures for handling money. What emerged from discussions, site visits and more discussions were some fairly stark choices: urban or rural? From whom can HNI accept funding? Who will be the members they seek?
Where to from here, Anando?