‘Normalise conversations about mental health in rural schools; ASHA workers, teachers could help’

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[00:00:32] In July 2024, for the first time ever, the economic survey spoke extensively about mental health and implications on policy. The survey acknowledged mental health as an impactful driver of individual and national development. What's worrying is that the NCERT Mental Health and Wellbeing of School Students survey highlighted an increasing prevalence of poor mental health among adolescents worsened by the COVID-19 pandemic. Roughly 11% of students said they felt anxious, 14% felt extreme emotions, and the impact of mental health.

[00:01:01] And 43% experienced mood swings. I want to focus on rural students in this episode because access to mental health care is tougher, often non-existent for students in such areas. And I think we should discuss more the intersectionality of education and mental health, especially in rural India. All Indians Matter.

[00:01:25] We have on the show Snehal Joshi, a psychologist, mental health educator and social entrepreneur with more than 17 years of experience across the health care and mental health sectors. She is the founder of Tatyam Consulting, where she designs and delivers mental health programs for corporate and educational spaces. Previously, she co-founded Heal Station, a rural health care initiative that provided primary medical care to more than 1.27 lakh patients and led a rural mental health program supporting more than 32,000 individuals across 40 villages.

[00:01:53] With extensive experience in school mental health and training frontline health workers, Snehal brings deep insight into the challenges young rural students face and practical strategies to address them. Snehal, welcome once again. You've been on the show once before. Yes, I have been and I'm very excited. So welcome and let's get into it straight away. Snehal, what is the scale of the mental health issues faced by rural students in India? Is that a very high prevalence? Yes, actually.

[00:02:19] In general also, as you mentioned that with the surveys happening, the amount of in general also the mental health in India is very, the condition is very poor. And the numbers are a little more in this age group, which is an adolescent age group. The reasons being that some of the severe mental illnesses also start in the adolescent age group like schizophrenia or bipolar, etc.

[00:02:43] Right. But if you say that 10% of common people have depression anxiety, that percentage is higher in the adolescent, which is almost 14%. I'm only talking about the research done in rural, for the rural students. Also, there is anxiety, as you said, social anxiety and also societality is also a big part, which is almost like 7 to 8%.

[00:03:08] So we think, usually we think that in rural, we are close to the nature. You know, we have a very easy life, very slow life. So as compared to the urban students, there is no performance pressure as much and all of that. And we would think that rural students have it easy a little bit than the urban population. But that's not the case. The numbers are equal or rather more. Snehal, you've been in this space for a long time.

[00:03:36] What are the differences in the mental health challenges between urban and rural students that you have observed? Okay. So just for our listeners, let me just state the common issues that all the students face. And then we'll go how the urban and rural differ. So first of all, anxiety and stress because there is fear of failure. So in this age group, students specifically are trying to identify themselves as who they are.

[00:04:04] The self-identity is being explored in that. So there is performance pressure. There is uncertainty. Then because the technology is such a huge part of our lives now. So there is, you know, hopelessness, loneliness, lack of human connection. Then there is also bullying or peer pressure. That kind of thing people go through. Also a lot of family conflicts now happen that we see that the parental relationships are quite unstable.

[00:04:31] And that impacts the adolescent age group. So that also impacts their academic performance at times. And I work in with teenager parents, etc. And the amount of issues that they're facing are growing more and more, right? Now, specifically talking about if you're comparing about urban and rural students, the academic pressure, as we say that for the urban students, the academic pressure comes from, hey, you need to get these many masks.

[00:05:00] Hey, you need to do this and do that. And, you know, career expectations or going to a lot of tuition. But with the rural students, that pressure is to how to get the skill set to get jobs in future. Some of the students at early ages need to start working or start doing some kind of labor to gain, to earn the money for the home, you know, all of that. Or they have fewer role models than the urban people.

[00:05:28] So that also plays a part in academic pressure. That's basic difference, right? Then the social models are quite different. Here, the urban students get a lot of autonomy. They get a lot of say in their career choices. Generally, a lot of parents would also go for career tests, etc. And that doesn't happen with rural students because the resources are not there.

[00:05:52] And they also deal with the impurity complex when they're coming to cities sometimes for further education and all. But that is also quite a different that impacts their mental health. Then with the parental and family issues, right? There are very high expectations from the parents in terms of academic in urban area. But with the rural, it is more of gender-based expectation is much more. So the women in rural area, female students for that matter in rural area,

[00:06:21] they are not pressured for expectation, which means that they don't get even converted to educated, self-sufficient, academically doing well kind of zone, right? So they are not enough motivated itself. And sometimes a lot of families in the rural area face domestic violence. And that impacts a lot of students there. And obviously, the technology is a big part of urban population.

[00:06:49] But it is no more that the rural students do not have access to mobile phones. At least one person in the house will have a smartphone. But basically, they do not know how to use the smartphone to their advantage, right? Which is, again, a problem in urban also. But at least as we talked about COVID, right? In COVID, rural students did not use the phone to get classes or, you know, these things like that. They literally lost two years, complete two years, right?

[00:07:17] Which didn't happen with urban students. And then they sometimes live in joint families. So that structure is quite different. That is another pressure situation. Also, if they're suffering from any kind of mental health issues, they do not have therapists there, psychologists there, school counselors there. You know, all of that is there. There is also a taboo. So all these issues are like very different in urban and rural.

[00:07:43] So their pressure is more from how can I soon earn the money? And I'm talking about that socio-economic background in rural as well. Which pressure people do not have even till 25 in urban. And now if you can say that. Some people, some parents say that you do your post-graduation and you take a couple of years to travel and then you can earn per year. So that kind of liberty rural students do not have. So definitely impact them mentally. Absolutely.

[00:08:11] I think these factors are not very well understood by people outside of rural areas. But, you know, focusing on rural schools at first, they're primarily about delivering basic education. Why does it make sense to include mental wellness as part of that effort? First of all, again, when I was working in Bihar, right? We used to do this school mental health program, which was basically destigmatizing mental health.

[00:08:37] So we used to talk about how mental health should be treated similar to the physical health issues, etc. Right? And I agree that schools are struggling with basic education there. Right? The infrastructure is there, but the quality of teaching is not great. Or the consistency in the students coming to school is very poor. So, but what I feel is that in adolescence, right?

[00:09:05] Your self-identity crisis goes a little high. Then also there is chances that you, if you are suffering from a severe mental disorder, which also is part of mental health, like schizophrenia, bipolar, it is important that to be identified at least, right? In order to help them. Then we are also thinking about some children might be, let's say, mentally retarded. Some might be autistic. Some would have learning disabilities and they might have not identified.

[00:09:33] And then how you can make autistic and children with learning disability part of the normal flow of the education, right? So, that is important. And the most important thing of mental health is substance use. So, a lot of these children in the rural schools get exposed to substances very early because it's so easily available, especially chewing tobacco or cigarettes. Or nowadays, even the higher drugs are available or sniffing the glue kind of thing, right?

[00:10:02] So, if we have awareness and the students know the impact it has on the brain and how to basically just identify things, even if it is limited to identification as a first step, it would help greatly to improve the overall mental well-being. Also improve the quality of education or the quality of life per se.

[00:10:25] And I've seen that with smaller, smaller things, the suicidal issues also come into play, right? Where they're feeling helpless, etc., etc. So, that also will reduce. So, it makes sense that anyways, they're coming to school. So, as midday meals have, you know, pulled them to school, it's better we utilize that infrastructure and push our mental health agenda there to improve the quality of life. It makes sense.

[00:10:52] And it will also help the villages because students will spread that knowledge in the village. So, I think that will make sense. Absolutely. And I think also it's important to understand that usually villages have access to primary health centers and not full-fledged hospitals. And so, obviously, those people, the staff in primary health centers are not trained or equipped to treat mental health illnesses. Right.

[00:11:16] I mean, I would agree to you completely because we started this hospital, small hospital in the tribal area in 2017. And we ourselves, like we had one MDBS doctor and I was there as an administrative person and engineer. So, I didn't know anything about mental health. And we didn't know how to even identify depression, anxiety and what are the basic medicines for it. So, we got ourselves trained through Christian Medical College, well-known PGDMH program,

[00:11:46] where they teach actually the primary healthcare workers also and the MDBS doctors also on how to treat basic mental health illness. Okay. So, I completely agree. Now, when we are introducing the school mental health, their identification can happen, where students or teachers can at least identify what is the problem. But the next level would be treatment, which means medications or counseling or whatever.

[00:12:12] So, it is very important to involve whoever is working in PhD to at least have basic mental health training. Otherwise, the psychiatrists are not enough. They can't go to the rural areas and station themselves there. So, I remember we were working on the Indo-Nepal border and the nearest psychiatrist was either in Gorakhpur or in Patna, which is like 150 kilometers and 250 kilometers away. No other health was available.

[00:12:41] Right. Right. So, it will be very important to use the existing infrastructure and give them the skills to treat rather than trying to bring the force to rural. You know, I think that's a critical point. And it's a good time to raise the option of the ASHA worker because every village has an accredited social health activist or ASHA worker. And an ASHA worker is a health worker who acts as a bridge between the community and the public health system. Right.

[00:13:10] And is involved in nearly all health programs, especially with children, from immunization to disease prevention. Do you think they can be trained on mental health issues to help deal with the overall issue? I'm not suggesting necessarily that, you know, they deliver medical treatment, but is there a way that they can at least help initially? I'm so glad that we are handling this question because that's exactly what we did in the station model. Right.

[00:13:38] So, this rural mental health program model was based that you do a survey in the village and that survey is done by mental health workers. And those mental health workers were not highly educated people. There were 10th and 12th past people who had this 12th questionnaire, which used to go to each family, ask. And then we would see the patients which were probably having any mental issues, not confirmative thing. Right. It's a survey.

[00:14:06] So that and then an ambiguous doctor used to go to the villages, check the patient, see if they need medicine or therapy. I was trained in group therapy. Some of our health workers were also trained in group therapies or the basic psychoeducation that we call that, educating people about their conditions and basic support. Right. And that's how we could cover 40 villages with only 10 health workers, myself and Dr. Gaurav. Right.

[00:14:34] An ambiguous doctor, an administrative person and 10 health workers who were all females in the land. Right. And they could cover 40 villages and we could reach up to 32,000 people. So if we do it on the mask where the government already has a health worker network. Right. If we just upskill them and incentivize them for this work, it might just work. I mean, it would be great. It has worked well in maternal health.

[00:15:04] It has also worked well in neonatal health. Right. So this might work in mental health and we have a proven model that it works basically. And all we did was a five-day training to the health workers, not more than that. And we had to just do revisions over the time. Right. And as you said, there's an existing infrastructure in the form of the ASHA network. Yes. Snehal, you already talked a little bit about how COVID-19 affected rural students. Could you elaborate a little more on that?

[00:15:32] Because that seems to have been a real inflection point when it comes to rural mental health challenges. Yeah. So COVID-19 was very different in rural than urban. And I can say that because I feel like right from start to end during COVID, I was completely in rural. I didn't even go to urban area to visit my family or anything. So those two years were very, very difficult economically for the family. Right.

[00:15:58] Because somebody was working outside, they were not getting full of them. There was no work other than some little bit agricultural work here and there. Right. So there was a huge economic crisis and setback. And when you have huge economic crisis at home, the one thing that you will deprioritize is education because it's optional. It's considered mentally as an optional thing. Right. That, hey, if he doesn't get educated, he'll do some labor work and, you know, get money.

[00:16:27] So education doesn't become a priority. So that got reduced. And now what happened was access to education is cut. So that part of part is gone. Then there is economic pressure at home. So you have to step up. The students have to step up. The girls would, again, take care of the home so that the mother can go and earn money. So they are also confided to doing home chores or anything like that. So what happened was education disruption happened.

[00:16:56] Isolation happened because whatever me time they were getting by going to the school, that stopped. And the economic strain also happened. So a lot of people actually left the system itself. And they started doing some job or something like that and all of that. Because they can't take two years off like we can do, right? They don't, they can't sustain like that. So I think mental health wise also, if we see the mental health impact of COVID-19,

[00:17:23] a lot of isolation and loss of education time, me time also impacted like stress, anxiety, etc. And I think of the people who left the system, as you mentioned, it is widely believed that many of them haven't yet come back. Which brings me to the parents. We already spoke about lack of mental health awareness in schools itself among teachers and staff. But there's a lack of awareness, especially among parents also, isn't it? Yes.

[00:17:52] I mean, that is a case of all educated urban parents as well. I would say that they do not have complete idea of what mental health issues in teenagers look like. And that has been my experience lately. And I don't blame them. They haven't been taught. But similar with rural parents as well, rather even more problematic is because urban parents can go and Google and read about it and talk to their colleagues, etc., listen to the podcast and all of that.

[00:18:20] And none of these resources are available for rural parents, right? And their priority is not to understand because they're already dealing with so much. They're dealing with economic strain. They're dealing with physical illnesses for which they do not have enough money. And imagine mental health being a priority. And lack of awareness starts from the cultural stigma as well. Like that culture is like if somebody is having, let's say, hallucinations.

[00:18:46] And hallucinations are hearing voices or seeing the people that are not there, right? Or delusions. So they would look at it from a very religion or magico-religious belief, right? They would say there is some black magic has happened. So they would take the person to a temple or to a... So that kind of stigma already is there, right? Also, they do not know any better whom they are going to take. There are no therapists. There are no psychiatrists, right? So they do not know.

[00:19:13] So even in that base knowledge, if we deliver in the school mental health program, that will actually pour down to the parents. The only way to go to parents is either having rural mental health programs or training the ASHA workers or including that as an education to the students who can in turn teach the parents. The parents are already out of that system, right? So we need to bring them back. Absolutely. And which also you mentioned it briefly, but it's worth talking about a little more.

[00:19:41] Is the social stigma attached to mental health challenges and seems to be stronger in rural areas? Yes. So in the party villages that we work, right? And I'm going to talk about very personal experience here, right? So two of the girls that I was working in the village were going through extreme depression and I didn't know because they didn't come and speak. Because we had just started working in the village and we hadn't built that much trust with the villagers. And we lost those two girls to suicide.

[00:20:12] Yeah? That has been my personal, personal belief. Now, parents didn't know any better, right? Because there was a stigma that she is feeling sad because somebody has done something to it. It will either go away or if I pray enough, she will be fine. Or one of the family didn't even identify that the girl was going through so much, right? They only came to know when she took her own life, right?

[00:20:39] So this can be, mental health is generally looked from a very magical religious lens still. Still. And there's a huge percentage of that which we need to change, right? And it will slowly change by programs like rural mental health or training the Aasha workers. Second is there is no awareness. They do not know this term, which we also came to know 10 years back, right?

[00:21:06] The conversation 10 years back started getting stronger and stronger. And now that is going a little bit into that direction where there are a lot of NGOs that walk into mental health space, specifically into rural mental health space. Now that dialogue has been started. So the awareness is coming back. But yes, because of lack of awareness, the identification won't happen. They won't get the right help. And the mental health issues won't be resolved.

[00:21:31] So Sleena, we've talked a little bit about Aasha workers and school managements, you know, being more aware of mental health challenges. But I also want to talk about teachers specifically who have the most interaction with the students. Now, obviously, they can play an important role. What can be done to sensitize them more?

[00:21:52] I mean, as we see, right, similarly, as Aasha workers should go through this basic training so that they can help everybody, not just students, right? Because Aasha workers handles the whole village and specifically has access to the whole population, right? Similarly, teachers have a specific group. So they can be trained in an issue specific to Adilusa, right? And that would be really good.

[00:22:16] Even if they're just able to identify issues that, hey, if somebody is going through depression or somebody is going through having a weird behavior or that is, which is not normal behavior, abnormal behavior, or somebody is consuming drugs more or something like that. They will be able, if they're trained to specifically in just identification and referral of students, right? Yeah, that you just identify and then send them to the PHC or wherever the next service is available.

[00:22:43] Even if they're trained in that, that will be a great thing to do. Second thing to do is they have to start this conversation in the school. They have to normalize these topics, right, by talking about it. So when we are saying that we want to implement school mental health program, I remember doing this program and even teachers used to attend the programs and used to be mesmerized. Like, we didn't know this. I wish I knew this, right? So they can be part of that whole ecosystem really well.

[00:23:13] But also with identifying mental health issues and getting the right help, they can control the dropout rates, right? That happened due to mental health, right? So that can also be one win-win situation because teacher would definitely have some kind of influence, good or bad, but they have the power. And rural has seen that students still listen to teachers and their parents do not go to question teachers as much as they do in our village. I think there's a very reverential position still for teachers.

[00:23:42] Yes, teachers, yeah, they do get all the respect that they deserve. I'm not saying that they don't, right? And also, if we identify a little bit, again, I'm not saying whatever small population we have with learning disabilities, especially mentally retarded children, they're usually not even sent to school, even in lower grades, right? And that also takes away a lot of quality of life from them.

[00:24:06] So even if they could just identify the basic things there, also I think giving some special treatment to those students, giving them more time and not allow them to drop out from the system, the special children. So that would be also a great advantage if we train the teacher. So, I mean, if you look at the overall solution now, what is the way ahead for rural schools? Do you think the answer lies at a policy level?

[00:24:30] So, again, even in CBSE and as you said, NPRT, they all have mental health in their curriculum, right? And even the NEP that has come now, we had this discussion in our psychology class. The new education policy. Yes, the new education policy. They also identify the need for mental health. So, counsellor is simple for in every school. It's just that government schools are not implementing it themselves. They have only made the policy.

[00:25:00] But they are not recruiting enough counsellors to just depute them to rural schools, you know? And I think it is similar to... I mean, policy level change, I think they've done, which is a great thing. I'm not trying to demotivate the government. They are taking the steps. But implementation is something that we struggle with. And, you know what? Even if not counsellors, there are psychiatric social workers.

[00:25:30] There are mental health workers, right? So, they can create a parallel mental health worker force also who can be trained in basic therapy skills, basic identification. And they can be stationed in schools is what I think. And so, in turn, if they have the knowledge, they can pray to Asha, they can pray to teachers, they can pray to students. So, students will have somebody to talk to openly, you know? And that happens in urban schools.

[00:25:58] And every urban school nowadays has a school counsellor. What they do is a different story. But they do have at least the access, right? Where parents can go and understand what is happening with their child, etc. So, I think that even if I'm not getting psychologists per se, there can be a workforce which is trained in basic things. That I think would be a better idea. And it's a great first step. Yes.

[00:26:27] So, sticking to a more fundamental question here. If we were to achieve better mental health in schools, in rural schools specifically, in tangible terms, what benefit would the country see? Now, I mean, you know, you asked me tangible. So, I'm going to stick to tangible. Obviously, intangible is the quality of life which we are striving for. You know, the whole world is striving for better quality of life for everybody, right?

[00:26:54] So, I think first and foremost would be better academic performance. That they would academically do better if the mental health is taken care of. Because they can focus on learning. They can also normalize mental health issues. They get the right help. So, that can be there. And we are not talking about 1 or 2%. 10, 13 to 14% children are going through this like adolescent age group. So, we are talking about making that kind of impact. We can reduce, as I said already,

[00:27:23] that we can reduce the dropout rates. Also, we need to understand that the employability will go high. I see a lot of rural students getting themselves into addictions very early on. And addiction is a mental health issue, right? So, you know, by educating them beforehand, talking about brain and impact, that also will improve. Because one, you are into addiction, your employability, everything, everything goes down, right? So, better employability will be also there.

[00:27:53] They will be more confident. They will be emotionally healthy. Somebody can prepare them when they are going to cities, how to handle that kind of difference in the environment, right? So, better workforce, I would say. Right? Then, even though, I mean, again, this is not, again, very specific to rural, but I'm going to cover it. Also, if you see a lot of defiance, which means oppositionalism in the adolescent age,

[00:28:19] they might go on the road of trying at some point, you know? And if that is not identified at the right age and not worked upon, we can also see that as a tangible impact that you will see lesser crime rates. And I might be far-fetching here a little bit, but, you know, but that would, they wouldn't get into that kind of thing due to mental health issues I'm talking about. And obviously,

[00:28:46] we'll have a healthier generation coming up and who have good mental health habits and, again, again, a little intangible, I would say. That will have a better generation. Absolutely. And all of this has a very tangible economic impact. A better workforce obviously produces more and is more efficient. So, that brings me to Dathya. Tell us about that. Yeah. So, after working on rural mental health for so long,

[00:29:15] I got really interested in mental health. I got myself a master's in psychology, which, after my engineering and everything, all the students in B.R., I got trained in that. And now, currently, I started Tathyaam Consulting. And, I mean, again, there is individual therapy, there is couples therapy. I also, because I've worked in corporate, I also work on leadership coaching and corporate training. But my aim is to solve this issue of mental health awareness.

[00:29:45] And I do that with schools, NGOs, as you said, ASHA workers. There is also a lot of NGO workforce, which is already working in education, health, etc., in rural areas. NGOs. And also the corporate. Because the stress is going high and high and the mental health issue is getting out of hand. It also impacts the productivity, the culture of the company gets impacted, and all of that. So, I'm working with multiple stakeholders here. But my main interest is into mental health training

[00:30:13] and leadership coaching. So, here's a question that you are familiar with, because I asked you this question on the last show also. But I ask this of all my guests at the end of the show. Why do you do this work? Because I, myself, have gone through mental health issues at some point in life. And I feel that I should have gotten the right help at that point. And I didn't know. And after a certain point in time, my sister pushed me to seek help. And I got help. And it got better.

[00:30:43] And I think I would have missed a lot of years if I wouldn't have addressed it. So, that is my personal, personal reason to follow this. Also, I think that there is so much gap. Right? I mean, in rural, at least there are no resources there. So, it is such an important work to do if we want to have a healthier generation, as I said. And so, that is my goal. Even under Satyam, I want to reach to the rural area. And that's what I'm working on.

[00:31:11] And I don't think mental health is a luxury. I mean, it is so mis... This is a misconception that people think that taking therapy and taking help for mental health is a luxury. It is not. It is a necessity. And it was always a necessity, not because of COVID-19. It was always a necessity which has come to the surface now that it plays such a big role in everybody's life. So, I feel very passionate about this. Snehal, thanks so much for being on the show. Yeah. Thank you.

[00:31:40] Thank you so much for inviting me. It's such fun answering all these questions.