In The Dragons Den Turning The World Upside Down? By Jane McGrath

February 4, 2014

The Turning The World Upside Down Mental Health Challenge was a 2013 competition set by independent cross bencher Lord Nigel Crisp who has been both Chief executive of the NHS and  permanent secretary of the UK Dept. of Health. The challenge was part of his long term project Turning The World Upside Down, (ttwud.org) and it sought to identify mental health projects, practices and ideas from low and middle income countries which can be effectively applied to the challenges faced by high income countries.

The challenge received 34 case studies from all across the world and 4 were to be presented and discussed by a ‘Dragons Den” style panel at an event in London and a winner chosen. The request that I should join the panel came completely out of the blue and I have to say that I was really excited at the thought of being a dragon!  My other fearsome ‘dragons’ included Baroness Hollins, professor of the psychiatry of learning disability at St George’s, University, London. (She was also President of the Royal College of Psychiatrists from 2005 to 2008), Phillip Campbell, Editor-in-Chief of Nature and of the Nature Publishing Group, Paul Farmer, Chief Executive of Mind and Claudia Hammond presenter of radio 4’s very well respected programme All in the Mind. I had (I think) been invited because I am a mental health service user myself and am in the process of making a documentary called Mudpacks & Prozac which looks at what can be learned through mental health practices in rural Kerala  – its particularly looking at recovery that occurs outside of the western allopathic model through such models as Ayurveda and in local spaces such as temples, at festivals, pilgromages and in Brahmin healing houses. I really do believe that there is a lot that can be learnt or remembered by looking at other health systems outside the one we have developed over here.  I had been driven to make my film after sadly experiencing the very worst of mental health care that can possibly be provided in the UK. And a personal realisation that the existing NHS system and its medical model made absolutely no sense at all – in fact it seemed slightly bonkers. But that’s another story. What had been very clear to me as I traipsed around rural Kerala for 2 months, as a one woman film crew was that we sure have a lot to learn and certainty shouldn’t be exporting the model that we currently have in the UK. As Nigel explained  “countries with fewer resources, and without the baggage and vested interests found in high income countries, often cultivate their own unique climate for innovation and finding practical solutions.” That I knew was definitely true. I agreed to take part with great excitement.

 

I wanted then to share with you The Dream-A-World Cultural Therapy intervention for promoting resilience in High Risk Primary School Children in Jamaica and consider why to me and the rest of the panel it seemed head and shoulders above the other shortlisted entries. It was our hands down winner.

Dream-A-World (DAW) Cultural Therapy was presented by Frederick Hickling, Professor Emeritus University West Indies – his presentation to a packed room at The London School of Hygiene & Tropical Medicine was certainly lively, fast paced and delivered with a sense of energy and  passion that I had never seen before on a medical platform. I only mention it because it came up with the dragons as during deliberations we discussed if we had been won over by Prof Hickling’s charisma and not the project. Certainly not. We all agreed that it was simply the best and a project should never be discounted because the presentation style may be culturally different to that which a more reserved and objective medical audience might usually expect. That short exchange actually raises so many questions that were cited by Professor Hickling himself as he was pushed by the panel for larger samples of empirical evidence that his project works – the issue of trans cultural perceptions of knowledge and value.  This was also the same complaint that I heard time and time again in India where very senior Ayurvedic doctors and practitioners argued that their research is not validated in the west due to the insistence of using the western scientific model to test non western models, demands for scale, blind trials and complex control modeling to be consistently produced from inconsistent and pluralistic environments that are naturally in flux. Of course that’s not to say that extremely high quality research is not produced but if it does not meet strict criteria for scientific publication then it is simply not published and so doesn’t get the high profile of peer review and potential funding opportunities are lost.  The western model of medicine and its medical model fits so much more neatly into this system of quantitative analysis. When I was in India I filmed a fascinating conversation with Dr Manoj Kumar (managing trustee, MHAT – http://mhatkerala.org). I kept asking him about  his evidence and research and he said that they were just too busy treating people to invest in costly research, when I pushed him and said that published research would bring publicity and funding he said that every time they get publicity they are inundated with calls from people they have to turn away – he suggested that researchers from the west might want to come and do this but that they weren’t there to prove models but to deliver care. I found that challenging to hear at first but actually it makes more sense to me now I understand how difficult it is to meet the scientific criteria required for publication.

 

The DAW project is based in Jamaica and involves a multimodal intervention for high-risk primary school children living in impoverished, disadvantaged, inner-city communities, who are selected to be part of the project because of severe disruptive disorders and academic underachievement.

 

Dr Hickling described the proof of concept intervention that he used;

 

The project was implemented with 30 children from an inner-city primary school in Kingston in 2006, over 2½ years spanning grade three to six with evaluation of outcomes using The ASEBA (Achenbach System of Empirically Based Assessment) Teacher Report Form (TRF) (Achenbach & Rescorla, 2001) and end of term grades for the intervention group versus matched controls who were offered usual school supports. The goals of the innovation were to promote resilience, to increase academic performance, to increase self-control and modify maladaptive behaviors, to increase of self-esteem and wholesome identity formation, to increase creativity and productivity of high-risk primary school children. The initial pilot was a child-focused therapeutic model without parental intervention. It aimed to bring about behaviour change by seeding communities with ways of being that eschewed violence, substance abuse, and dangerous sexual behaviour and prioritizes achievement and gainful employment.*

The 30 eight to nine year-old students in the study cohort were selected by their teachers from the class that had just completed grade three, and were identified as high-risk based on their poor academic performance and behavioral problems. A control cohort of 30 students matched (non-blind) for age, gender and functioning were also selected.

Between June 2006 –December 2008 the DAW cohort attended three 40-hour summer workshops, twenty eight two-hour after-school follow-up sessions over seven semesters and three field trips to local places of interest. The control group attended the regular school program only. Each three-week (four days per week) summer program provided daily breakfast and lunch, language-arts and mathematics tutoring with basic computer skills. Each daily three-hour cultural therapy sessions combined guided group therapy discussion with creative arts (art, drama, dance, and music).

The children were asked to imagine a new world on another planet, name it and conceive its inhabitants, decide what to take or eliminate from their known world to this new one, how they would look and what role they would play in governing the new world. They worked with a facilitator in groups of six to record this information. The artists assisted the children with various art projects, taught them to play musical instruments, compose songs, poems and dances about their new world. These performance songs, dances and script were refined and performed over the 2½ years of the project. Each summer workshop culminated with a 15-minute performance staged by the children at a church within their school community, for an audience of parents, teachers, community members, staff and students from the local university, and media representatives.

Changes in academic performance were measured using the children’s grades for language art, mathematics, science, and social studies, obtained at the end of each academic year.  All 30 children from the ‘proof of concept’ pilot project failing the Grade 3 Primary School Test and exhibiting severe disruptive disorders, had passed the Grade Six Achievement Test 36 months later, and have entered acredited High Schools in Jamaica. The intervention group made significant improvements in school social and behavior adjustment measured by the ASEBA TRF, with more successful outcome amongst boys for behavioral gains. ( Prof Hickling, 2014)

So why did this particular project excite us so much?

Firstly it was preventative, it sought to work proactively with children through the education model. It didn’t involve the families or rely on them but used teachers who were trained and willing to engage. Also it included healthy food and encouraged and developed children’s artistic expression and crucially it gave them hope and acknowledged their value as members of their community. By helping them attain pass grades at such an early age it was a direct intervention that enabled them to continue at school to learn to read and write – this would directly impact their lives in a very immediate and real way. It was so hopeful and it was delivered by the community for the community using a system that already existed – school.

As children acting out behaviors are often clear signs that something is very wrong and the child needs attention and understanding not punishment and exclusion. That seems like common sense to me. Secondly the work seems transferable to the UK  – although I did question why such pioneering projects such as Camila Batmanghelidjh’s Kids Company haven’t been rolled out nationally?  Do they only work if there is a charismatic and persuasive leader – why aren’t they funded? It seems a short sighted decision not to invest in impoverished and disruptive children at such an early age. It seems to me that if you can support the youngest and most vulnerable children and prevent them from becoming socially, academically and economically excluded then the chances of serious and enduring mental health problems diminish and their life experience and the experience for their communities will be more positive. There is of course an enormous financial argument for this…but maybe the research isn’t there? Maybe it is? Does any one know?

Do you think that Dream A World projects could be rolled out in the UK? Or is our education system not strong and steady enough to support this? Or is it overstretched already? I’m not an academic or psychiatrist so Im really interested in your thoughts or any examples you have of preventative projects like this already in the UK.

Jane McGrath

Contact Jane via Twitter 

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