Innovation summary

Approximately 150 million people in India are in  need for mental health care. However, the treatment gap in India is as high as 84.5% for diagnosable mental health conditions1. The stigma against mental health, affordability, accessibility and lack of trained professionals hinder help-seeking. In this scenario, iCALL, a field action project of School of Human Ecology, Tata Institute of Social Sciences, was initiated in 2012, to bridge the vast treatment gap.

iCALL provides professional, anonymous, confidential and free counselling services through technology-assisted mediums of telephone, email and chat to anyone experiencing psychosocial distress (including those with a mental health diagnosis), with a special focus on marginalized communities. iCALL offers services in 9 different languages, across age, gender, sexual orientation or race, transcending geographical distances. iCALL’s counsellors offer a safe and holding environment to those in distress and connect clients to multisectoral referrals as per their needs.

Impact summary

  • Since its inception in 2012 till April 2020, iCALL has offered its services over 1,16,671 sessions across calls (92531), emails (22981) and chat (1159). 
  • Clients have reached out from 26 states of India, 5 union territories and 22 other countries.
  • iCALL has a follow-up rate of 56.4%, i.e. over half of all clients reach out for long-term counselling
  • iCALL’s model has been replicated by several state governments in India, catering to various psychosocial concerns
  • INR 40 (0.55 USD) covers the cost of a single session (whether it is over call, email or chat), but free for beneficiaries.

...iCALL counselling is simply amazing and makes life full of joy/ happiness/ worth-living full of bright colours. Counsellors with their expertise have brought new dimensions addressing real life problems/ new perspectives to pain areas/ new directions for growth and mental well-being while taking-off all the negative unwanted stress.”

 

- 41 year old male client from Mumbai

Innovation details

  • Mental health services in India, remain limited to an individualistic paradigm, thus not acknowledging the role of several socio-cultural determinants of wellbeing. Therefore, iCALL adopts a psychosocial approach to mental health and views emotional distress on a continuum with an understanding that a multitude of social determinants like (gender, age, class, caste, religion etc)  impact wellbeing.
  • Through Technology, iCALL caters to a wide range of psychosocial issues such as violence, suicidality, self-harm, academic and career concerns, relationship issues, sexuality, mental health concerns, substance abuse and addictions etc.
  • iCALL offers its counsellors, three levels of supervision: peer supervision, one-to-one with trained supervisor and team debriefs and case discussions.
  • iCALL team is trained to understand concerns of clients coming from diverse, marginalised, intersectional and social locations.
  • Being located within an academic institution, iCALL’s work is backed by the academic rigour of adopting evidence-based practices, self-reflective documentation and continued engagement with research.

Key drivers

There are several factors working together which ensure that iCALL’s model not just sustains itself, but also ensures effectiveness. 

  1. Continued learning and development: Being situated in an academic institution, iCALL invests in researching its own model and its practices. Besides, it also engages in processes of self-reflection, by organizing consultations with experts and learning from their feedback to continuously keep the model evolving. It studies the needs of unique client groups and ensures that its counsellors are trained to respond to their unique concerns.
  2. Counsellor Self-Care: Besides providing a 3 layered supervision to counsellors, iCALL keeps a check on counsellor through team activities, such as mindfulness which are organized to help counsellors bond with each other as well as care for their own mental health.
  3. Use of Technology: As a result of using technology, iCALL is able to achieve a higher reach in less investment and facilitate access to marginalized communities who may not have access to professional mental health services.
  4. Strategic Partnerships: Creating like minded partnerships for publicizing the services, and for other collaborations have helped iCALL expand and reach to populations which otherwise, would not have been easy to reach out to.

Challenges

  1. Financial sustainability - With a limited number of organizations funding mental health initiatives, raising funds for services like iCALL is challenging. At present iCALL raises funds through philanthropic partnerships and capacity building initiatives. Money raised through partnership organizations and consultancy contributes to corpus building within iCALL
  2. Human resource - Certain features of iCALL’s work such as being able to work in shifts, and the requirement of having compatibility with iCALL’s values underlying its counselling model (of understanding intersectionality, of adopting a psychosocial lens as opposed to a clinical one etc.) make it difficult to find well-suited counsellors.
  3. Counsellor burnout - Given the taxing, repetitive and the emotional nature of counselling work, counsellors often experience vicarious trauma and burnout. In order to retain the existing counsellors, iCALL has implemented several strategies such as regular training, self-care allowance, self-care activities, ongoing supervision, team-building, value discussions, monetary increments, flexibility in work profile, conversations about vulnerability and health, taking judicious breaks etc. Even though iCALL undertakes these strategies to address burnout, sustenance of counsellors for a longer period of time continues to be a challenge.
  4. Finding the balance between sustainable expansion and the existing treatment gap- Being a community service, iCALL finds it challenging to cater to all the mental health needs of the community, given its limited resources. This is reflected in the form of calls going unanswered and delay in responding to emails. As iCALL expands its human resource, the client database keeps on increasing in a manner such that the challenge continues to persist.
  5. Impact assessment - When it comes to assessing impact of iCALL’s services, specifically measuring effectiveness, there are several kinds of challenges. Most importantly, as a result of working on psychosocial wellbeing, which iCALL believes, lies on a continuum, it is difficult to quantitatively define the point of the service having ‘effectively’ shifted an individual from distress to wellbeing. iCALL also uses a non-diagnostic and a non-clinical approach to wellbeing, and thus psychometric testing and assessment are not part of iCALL’s work with clients. Additionally, mental health services often have a secondary / snowball impact, which means that the resultant reduction in distress of an individual also has an impact on the person’s ecosystems such as their family, workplace and community. However, it is not possible to capture or quantify such an impact.

Continuation

In addition to service provision, iCALL devoted resources to strengthen its response through various other means:

  • Replication of the iCALL - model at national level - Capacity building of helping professionals within the larger field allows iCALL to strengthen the existing mental health services as well as replicate its own model; thus, taking a step towards bridging the mental health treatment gap. These helping professionals work within Government, Non-governmental, hospital and community settings. Till date, iCALL has partnered with six state governments (Maharashtra, Gujarat, Uttar Pradesh, Madhya Pradesh, Tamil Nadu and Rajasthan) to set up and strengthen various helplines and mental health services. iCALL’s learnings and insights about pathways of change (with respect to service delivery and operations) have also influenced policies and functioning of these services. 
  • Creation of knowledge : Rooted in an academic institution, iCALL strongly believes in researching its own model and undertaking independent research work that will contribute to knowledge creation within the mental health field. Technology, mental health, youth & adolescent mental health, psychosocial wellbeing, suicide & self-harm are some of the areas of research that iCALL has engaged in. Some research initiatives and knowledge products of iCALL include:
    - A research study exploring psychosocial stressors, support systems and coping among students appearing for competitive exams in Kota
    - A research study evaluating the effectiveness of the Prerna Prakalp program, an initiative of the Govt. of Mahrashtra to address issues of mental health and suicide among farmers. 
    - Best Practice Guidelines for working with adolescents and young people
    - Best Practice Guidelines for responding to suicide and self-harm for loved ones, educational institutions, media and mental health professionals.
  • Developing training programs: iCALL has also been involved in designing training curriculum and training programs on the basis of its insights and learnings. Two of these programs include: 
  • Fostering Strengths - A bi-annual short term training program which aims to train professionals working towards various aspects of psychosocial well-being of adolescents and young people in perspectives, knowledge and skills. About 100 helping professionals (such as teachers, social workers, counselors, medical doctors,  etc.) across the country have been trained over 5 batches of this course, since April 2017.
  • Samvaad- An integrated health counselling curriculum - run on an e-platform, is one of its kind in the country. It is being used to train over 400 SSK and RKSK counsellors in Madhya Pradesh and Rajasthan. This program is currently being considered for national replication.

Partners

iCALL’s partnerships include knowledge partnership, technical partnerships and , implementation partnerships, funding partnerships. iCALL is a partner with 20+ CBOs and NGOs across the country, working on a diverse range of issues.

Funder

Evaluation methods

Impact of the services offered over the helpline are largely quantitative in nature. Given the sensitive & anonymous services offered by the helpline capturing impact is challenging. Therefore the impact is measured quality indicators of the service as well as client data that corresponds the objectives.

 

Impact indicators included:

  • Number of clients accessing the service
  • Gender break up
  • No. of crisis sessions
  • Age distribution of clients
  • Average call duration
  • Diversity of language
  • Diversity of issues addressed
  • Qualitative feedback shared by clients
  • Geographical Reach
  • Follow up rate

Cost of implementation

The cost of one session at iCALL is 0.54 USD which is about INR 40, whereas in India the cost of outpatient care on a monthly basis ranges from INR 720-830 per client, i.e. 9.7 USD - 11.27 USD. When mental health services are accessed through the public sector, the minimum cost per month could be around INR 100 but if the same were to be accessed through the private sector, then the cost could increase by 10-15 times more, that is, around 1000-1500 INR per month2.

Impact details

Measuring impact of iCALL’s services is difficult because empirically, it is also difficult to isolate the role of other factors in the individual’s life contributing to this shift (or lack of it). iCALL being a technology-assisted service and with a policy of not following up with clients themselves, it is an ethical dilemma (considering client anonymity, autonomy, and confidentiality) to ‘track’ how an individual is doing across time, unless they share feedback themselves, which can be at irregular frequencies. iCALL has been also documenting client feedback over each call/email/chat when clients share it proactively. In addition to the indicators listed earlier, iCALL also relies on indicators such as the number of people reaching out to it, the number of follow-up callers, the geographical reach, the number of crisis calls etc. in order to assess the effectiveness of its services.

However, impact of iCALL’s service is assessed through the number of clients accessing the services, diversity of their profile/demographics and the nature of issues for which services are accessed.

  • Since inception in 2012 till April 2020, iCALL has offered its services over 116671 sessions, of which, 92531 were over call, 22981 were over email and 1159 were over chat. As compared to data trends in 2012, at present iCALL caters to seven times more clients on an annual basis.
  • iCALL’s services are accessed by female callers 44% of the time, while males access it 55% of the time and 1% of its services are accessed by transgenders.
  • With no time cap on the sessions, the average duration of a call is 25-30 minutes, some calls connect for over 90 minutes, as clients are allowed to connect with the counsellor for as long as they like. The client and the counsellor mutually decide if the concerns in that session are addressed and if the session can be terminated.
  • iCALL has received calls from 26 states of India, 5 union territories and 22 unique countries outside of India. Sessions have been offered in 10 unique languages so far, of which English followed by Hindi and Marathi are the top three languages used.
  • Lastly, the service has a follow up rate of 56.4% as of April 2020, which is an indicator of the satisfaction levels of the callers with the service.
  • So far, iCALL has addressed 6031 crisis cases including suicidality and violence - across phone, email and chat.
  • iCALL has worked with the state governments of Maharashtra, Gujarat, Madhya Pradesh and Uttar Pradesh to help set up psychosocial helplines, by consulting with them as they replicated iCALL’s model. The fact that various state governments have found iCALL’s model to be scalable and effective, goes to indicate the uniqueness of the model.

References

  1. Murthy, S. R. (2017). National mental health survey of India 2015–2016. Indian Journal of Psychiatry, 59(1), 21–26.
  2. Math SB, Gowda GS, Basavaraju V, Manjunatha N, Kumar CN, Enara A, Gowda M, Thirthalli J. Cost estimation for the implementation of the Mental Healthcare Act 2017. Indian J Psychiatry 2019;61, Suppl S4:650-9

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