The atmosphere in the event hall was busy. The PIECEs & the Avani team may have felt outnumbered, as the room was filled with service users (a welcome change), discussing what the event could be about. We shared, “It’s going to be all about you and your experiences with SALT,” and their excitement grew.

The fair created a space where the service users became part of something bigger. It redefined the traditional hierarchies by placing mental health professionals (MHPs) and service users on the same plane, as participants in an event. A space where all of us had something relevant, meaningful, and equal to bring to the table. However, language remained a significant barrier. While translation was available for service users who didn’t understand English, continuity in conversations still felt off, highlighting how language can divide professionals and patients. This was highlighted when a service user spoke about his relationship with his mother so emotionally that the translation could not do justice. 

The research team shares their dream for the mental health community

The mental health service users share their dreams for the future

On day one, we engaged in SALT conversations, not just as an icebreaker but as a way to refresh our practice and get to know each other. This allowed us to get to know the Avani team on a personal level. One particularly inspiring story was that of Anuradhaji, whose persistence and determination have shaped not only her life but also the lives of the children she rescues. She seems to grasp every opportunity that comes her way, with a clear vision of the big picture. It made me wonder, “What is my big picture? what kind of impact do I want my work to have?” 

Reflecting on this, I considered my own position, as someone raised in the city, a second-generation graduate, and an able-bodied woman with privileges that shape my perspective. Avani, on the other hand, works with some of the most underserved communities, where multiple vulnerabilities intersect, including extreme poverty and child labor in remote rural areas. Their approach is deeply intertwined with the lived realities of the people they work with.

A powerful example of community-led action came from Nandwal village, where local residents conducted their own research to understand why their village had high suicide rates. Often, we assume that people must first fully understand an issue before they can act on it. For instance, we believe that if people recognize mental illness as similar to physical illness or have more awareness about it, they will seek help sooner or not discriminate. However, the reality is more complex. Even when communities may not completely understand an issue, if it significantly affects their lives, and they feel some amount of ownership, they would find ways to make sense of it and act on it.

This made me wonder: How can we translate such community-driven efforts into our work with persons with lived experience of mental illness? Unlike Nandwal, where the community identified and acted on a shared concern, there is no existing community of persons with lived experience or caregivers that we can tap into. What can the government or non-profits do to address challenges that are deeply entrenched across an entire country? These questions remain unanswered. 

As we shared and discussed how SALT-CLCP has transformed lives, I found myself questioning: 

• How much of this transformation can be credited to the SALT-CLCP process?
• How much is due to the facilitators who guide the process?
• And most importantly, how much of the credit belongs to the individuals making the change themselves?

These questions lingered within me, as we listened to more stories of positive change emerging from the communities.

The participants respond to how SALT-CLCP has changed their perspectives

The SALT-CLCP Knowledge Fair was a space for reflection, learning, and inspiration. It reinforced the importance of creating platforms where service users are not just present but actively shape the conversation around their care. It also highlighted the ongoing challenges we face in involving the end user in conversations, particularly in bridging language and knowledge barriers.

As we move forward, the real challenge is not just in learning new or refining our methodologies but in ensuring that those most affected are the ones to lead the way in shaping solutions. As we remind ourselves that, creating change is not about introducing new methodologies, but about the people who bring them to life.

The QI workshops focused on empowering healthcare professionals with practical tools to drive small but impactful changes in their facilities. Over a total of five sessions, each lasting three hours, participants explored QI methodologies and their real-world applications.

A Step-by-Step Approach to Quality Improvement

The initial sessions introduced participants to the basics of QI, including the ELFT sequence and the Model for Improvement. During these workshops, participants:

• Identified specific problems in DIALOG+ implementation.
• Selected measurable outcomes, such as the number of completed DIALOG+ sessions.
• Applied analytical tools like the 5 Whys and Fishbone Diagram to uncover the root causes of challenges.

Building on these foundations, participants worked in seven groups to develop their own QI projects. Each group was tasked with defining a SMART aim and creating a stakeholder team at their respective facilities. These teams met fortnightly to refine their projects based on feedback and progress.

Practical Applications: Tools for Change

To deepen their understanding, participants engaged in practical exercises like process mapping, flow charts, and Pareto charts, which helped them visualize challenges and prioritize solutions. By the end of the training, healthcare professionals from Karwan-e-Hayat, Jinnah Postgraduate Medical Centre (JPMC), Lady Dufferin Hospital, and Karachi Psychiatric Hospital had developed tailored QI projects, each targeting key areas for improvement as follows:

• Workplace Improvement Initiatives: 4 QI projects aimed to enhance job satisfaction among healthcare staff and students by leveraging DIALOG+ sessions to address workplace stressors and improve the “job satisfaction domain.”
• Psychiatric Care: Two QI projects aimed to enhance mental health outcomes for patients and caregivers by using DIALOG+ sessions to improve ratings in the mental health domain. Another project focused on reducing average counselling time during follow-ups, particularly in high-volume community settings/psychiatric camps.

A Collaborative Path Forward

The collaborative efforts of local hospitals and the PIECEs research team underscore the potential of QI training to overcome DIALOG+ implementation challenges at health facilities. By equipping healthcare workers with the skills to analyze problems and implement targeted solutions, these initiatives are paving the way for more effective and sustainable use of DIALOG+ in Pakistan.

This journey demonstrates the power of small, consistent changes to drive significant improvements in mental health care delivery, offering a model that can be replicated across similar contexts.

Here are some key moments from QI workshops captured below:

QI participants from 3 private facilities, analyzing root causes using the “5 Whys” exercise

QI participants brainstorming sources of improvement ideas

PIECEs team demonstrating Fishbone exercise in a QI session

QI participants conducted a Fishbone exercise

QI Huddle with Project Stakeholders (Caregivers and Psychiatric Ward Staff)

Participants from the public hospital completing the QI workshops

PIECEs week was a celebration of the collaborative work between research teams from the Schizophrenia Research Foundation (SCARF) in India and Interactive Research & Development (IRD) in Pakistan. Their visit to London brought together experts to discuss findings from PIECEs and to reflect on how arts-based and other participatory approaches have bridged gaps in mental health care. The three-day visit included planning new research grants and brainstorming ideas for future projects. The teams also developed detailed dissemination strategies to ensure that the findings from PIECEs reach a broad audience, including healthcare providers, policymakers, and community members.

The teams also hosted a public event to showcase some of the most impactful elements of the PIECEs project. Attendees had the opportunity to learn how the use of storytelling through Theatre of the Oppressed and other participatory methods has enabled individuals with severe mental illness to express their experiences and challenges openly. This unique approach has been instrumental in improving mental health awareness in communities while also supporting system-level changes in India and Pakistan.

As the PIECEs project wraps up, the focus now turns to the future, with plans for ongoing research and continued partnerships across borders. This visit was a testament to the power of international collaboration in advancing mental health care, and we look forward to building on the project’s legacy in the years to come.

Take a look at some highlights from PIECEs Week captured below:

PIECEs teams from India, Pakistan and the UK

PIECEs public event at Clark Kenedy Lecture Theatre, Queen Mary University of London

Photovoice exhibition by Kasthuri Divya

A glimpse of Theatre of the Oppressed Performance at PIECEs public event

Prof. Victoria Bird, the principal investigator of the PIECEs project, delivered a talk during a symposium on psychosocial rehabilitation. At the same time, Dr. Mangala, India’s community engagement lead, highlighted SCARF’s outreach efforts over the past four decades. A dedicated hall displayed key aspects of the PIECEs study, including the clinical trial, community engagement, and small-scale research grants, led by individuals with lived experience associated with SCARF. The event also featured a Theatre of the Oppressed performance by SCARF’s theatre group, comprising individuals with lived experience of mental illness. The conference concluded with a lived experience panel, moderated by Dr. Suresh, where Mr. Anerudh shared his role as a peer support volunteer in the NIHR-funded peer support and small-scale research grants.

Illustrations by Parvathy (@prrrbutt)

As one walked into the exhibit space, the atmosphere was alive with interaction and conversations, but what truly stood out was seeing the service users confidently leading discussions. These individuals had been involved in different parts of the project, and now, they were in charge of presenting them. Whether it was the Randomized Control Trials (RCTs), Quality Improvement Workshops, or more creative aspects like the SALT (Stimulate/Share, Appreciate, Learn, and Transfer) workshops and the innovative use of community engagement through the Theatre of the Oppressed, the service users took ownership of their narratives. They eloquently explained each aspect, from the Namma Area initiative (a social hangout space for service users) to the visually powerful Photovoice Exhibit, engaging visitors with insights that only someone with lived experience could offer.

As part of their presentation, they didn’t just speak to the delegates—they also asked thought-provoking questions. These questions weren’t just about the project but aimed to spark deeper reflection among the visitors, such as how they might involve service users in their workplace settings, an idea that emerged from the service users.  This exchange turned the exhibit from a one-way dissemination into an interactive, reflective dialogue.

When asked about their personal experience participating in the dissemination, the service users spoke of how transformative it had been. For many, it was the first time taking up a leadership role in such a public forum. They shared how explaining the project, answering questions, and even presenting challenges faced by people with mental health conditions had a profound impact on their self-esteem. This involvement, they said, boosted their confidence and gave them a renewed sense of purpose, showcasing not only their knowledge but also their resilience.

The PIECEs Project presentation wasn’t just about sharing information it was a living example of empowerment. It gave a voice to those who are often spoken for, and in doing so, it highlighted the importance of including service users in mental health initiatives. Through their participation, the service users transformed from beneficiaries to advocates and leaders, leaving both themselves and the delegates with a lasting impression of the true power of lived experience.

The presentation featured a glimpse into the Theatre of the Oppressed, which illustrated the common challenges and opportunities in community engagement across these diverse regions.The team also used “The Great Game of Power” to prompt the audience to reflect on the key stakeholders and the role of oppressors within these communities. This interactive segment sparked meaningful conversations and allowed participants to share their perspectives.The session concluded with insights from representatives in India and Pakistan, followed by an open Q&A. The evening showcased the power of dialogue, creativity, and shared learning, leaving everyone inspired and eager for future collaboration.

You can read our plan here.

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For those unfamiliar with this concept, “Namma” is a Tamil word for “Our,” and Namma Area means “Our Space.” This innovative space for individuals with psychoses or any mental health issues embodies autonomy, freedom, ownership, and responsibility. It promotes socialization and recreation through activities like games, movies, reading, and visits to places such as museums or parks. Initiated two years ago under the aegis of the PIECEs project, supported by an NIHR grant, Namma Area has served as a vital platform for engaging communities. The anniversary event, held at Vani Mahal in the heart of Chennai, showcased the remarkable talents of the service users in theatrics, dance, and a dramatic depiction of the space, with the highlight being a powerful panel discussion. The panel featured individuals with lived experience who shared how being part of Namma Area had significantly impacted their lives

The panel featured individuals with lived experience who shared how being part of the Namma Area had significantly impacted their lives. One poignant moment came when a young woman, responding to a question about whether her symptoms interfered with stage performance, said, “New learning pushes back any symptom that I would experience – that is the power of this space.” Answering a family member requesting transport to Namma Area, another panellist was quick to respond, “It is our desire to open more spaces in several parts of the city – this will allow lots of people to be part of the space”

These heartfelt exchanges highlighted the immense value of lived experience in shaping effective mental health initiatives. The director of Scarf mentioned that, as mental health professionals, we have much to learn from those with firsthand knowledge. The day is not far when individuals with psychoses will advocate for what they want and how they want it, paving the way for more inclusive and supportive community spaces.

Namma Area’s second anniversary was a celebration as well as a testament to the power of collective community efforts in fostering mental well-being.