Rehabilitation of mentally ill women

Abstract

Women, the fair sex, are principal providers of care and support to families. But, they are considered to be the weaker sex and one of the most powerless and marginalized sections of our society. The provision of Rehabilitation for mentally ill women has been, and still is, one of the major challenges for mental health systems reform in the last decades, for various reasons. The present paper discusses the global and Indian scenario of rehabilitation of mentally ill women and goes on to detail the contribution of the state and voluntary agencies in this regard. It explores the need of recovery, multilayered strategy of Rehabilitation services and the availability of present services. The stigma attached and legal defects which interfere in good quality of life for the mentally ill women are reviewed. Strategies for changes in future are recommended.

INTRODUCTION

The seeds of psychosocial rehabilitation were sown in the aftermath of the era of de-institutionalization of the 1960s and 70s. The failures in the implementation of the policy of de-institutionalization when patients hitherto confined to custodial type of mental hospitals were released into a community, which was not yet geared to receive and accommodate them, ended up with these patients facing a fate far more worse than when they were institutionalized. They ended up as destitute whom neither the hospitals nor their families were able to take care of. Thus, the end of the twentieth century witnessed the springing up of a number of alternative community-based as well as in patient settings. The focus was not just symptom relief but also helping the individual achieve a maximum possible level of functionality in all spheres. It is in this realm of psychosocial rehabilitation that the special needs of women were recognized. If psychosocial rehabilitation is still a child, then the field of gender sensitive services for women is in its infancy, but thankfully both are heading in the right direction as is obvious by efforts made by governments and policy makers all over the world.

GLOBAL SCENARIO

Rehabilitation services in America took the form of clubhouses and successful models, like Fountain House, were replicated in numerous other countries, one prominent example being the Fountain House project in Lahore, Pakistan.[1] Especially noteworthy, among the gender sensitive rehabilitation services in the United States, is the Thresholds Mothers’ Program, which was the first such venture in the country to be launched in 1976. This nongovernmental program focuses on parenting skills and aids mentally ill women in becoming better mothers and taking care of themselves and their families. It includes clinical and rehabilitation services, education and support, training in stress and household management, and education in child development.[2] In 1993, Tipper Gore, President Clinton's mental health policy advisor, recognized the program as one that “sets an example for the nation to follow.”[3]

Other countries like Canada and the United Kingdom have now incorporated gender based analyses as well special policies for overall women's mental health in their services, but there are still no clearly defined rehabilitation programs for mentally ill women.[4,5]

More ever, research on rehabilitation services for those with psychiatric disabilities, studies suggest that, on the whole, service delivery models in the United States of America fail to address needs specific to women with mental illness, in general, as well as those of women experiencing severe depression.[6]

THE INDIAN SCENARIO

In keeping with the worldwide trend of de-institutionalization, in India too, the closure of custodial type of mental asylums is occurring. With the asylums being converted into hospitals, the number of long-term residents is also dwindling. Hospitals do not encourage unnecessary long-term admissions and abandonment by families is not as common as before. However, discharging mentally ill women back into a community which is not ready to receive them is fraught with evil consequences. A family who is not ready to accept the mentally ill woman back into its fold, is unlikely to ensure adherence to treatment and regular follow-ups and the woman is thus at a risk of repeated relapses and worsening of her psychiatric condition. Stigma and discrimination by the society may abet abandonment and exposure to both physical and sexual abuse.

Added to this problem, is the unfortunate fact that a majority of the mentally ill women as well as men, especially those residing in rural areas, do not have access to, are not aware of or do not avail mental health services. Faith healers play the role of mental health practitioners, and religious places and shrines act as residential centers for the chronically ill. The inmates once labeled mentally ill, sometimes spend their entire lives in such places in overcrowded, inhuman conditions.

The 2001 Erwadi tragedy in which 28 mentally ill persons who were kept chained up, were charred to death in an accidental fire, was an unpleasant eye-opener to the stark reality of insufficient rehabilitation services available to the mentally ill. Following this incident, 571 mentally ill people, who were kept chained, were rescued from 15 so-called “mental homes” that were functioning around the dargah, in Erwadi of Ramanathapuram district of Tamil Nadu.[7]

The Supreme Court suo motu issued notices, on the basis of media reports on the tragedy, to the State and Central governments asking them to submit a “factual report” and ordered the mapping of all faith-healing homes in the country. The Centre also ordered the implementation of the guidelines for maintaining minimum standards in mental homes.

Following this incident, the National Human Rights Commission (NHRC) in 2001 asked all States and Union Territories to certify that no mentally ill patients were chained or kept in captivity, so that any future recurrence of similar tragic incidents could be prevented.[8] The same annual report also mentions the inauguration of a halfway home for cured female patients at Gwalior Mansik Arogyashala and a special drive to relocate cured patients back into their families which were previously reluctant to do so.

And then once again, the media brought attention to the issue of homeless mentally ill women, when it highlighted the case of Gitanjali Nagpal, an erstwhile successful ramp model, who was found to be begging in a disheveled, unkempt state on the streets of New Delhi. Apart from suffering from psychosis, she had also fallen prey to drug abuse.[9] If the Erwadi tragedy brought attention to the human rights of the mentally ill, the Nagpal media coverage spurned the government to recognize the special needs of the mentally ill women and plan services, especially catering to this extremely vulnerable population.

CONTRIBUTION OF THE STATE

The Government of India has been handling the subject of mental illnesses through two major legislations, The Mental Health Act (MHA) of 1987, and People with Disability Act 1995 (PWD Act).[10,11] The MHA, which deals with treatment, comes within the domain of the Health Ministry whereas the PWD Act is the responsibility of the Ministry of Social Justice and Empowerment. Apart from laying guidelines for the treatment of the mentally ill, the MHA also gives directions for setting up mental hospitals. The Government and the Health Ministry have been providing mental health services through the National Mental Health Program, which has treatment and rehabilitation of the mentally ill within the family setting as one of the primary objectives.

In the 11^th Five Year Plan, the National Mental Health Program has been re-strategized, and it is to be synchronized with the National Rural Health Mission for optimizing the results. The plan proposes to strengthen the District Mental Health Program (DMHP) and enhance its visibility at a grass root by promoting greater family and community participation and creating para-professionals equipped to address the mental health needs of the community from within. Extension of the DMHP to all the districts of the country is also being done.[12]

The Ministry of Social Justice and Empowerment deals with the rehabilitation of mentally ill persons. To address the issue of stigmatization, a scheme was launched to set up ten halfway homes for the welfare of those persons who are not accepted within their families. The Ministry has also been encouraging Non-Governmental Organizations (NGOs) to come forward and take the initiative in setting up more such homes. Previously the focus of rehabilitation efforts were mainly focusing on people with physical disabilities and mental disabilities were often ignored. Under the PWD Act, this changed, and persons with mental disabilities were now eligible to various benefits like reservation in educational institutions, preferential allotment of land and reservation in poverty alleviation program. Families who were otherwise tempted to abandon their mentally ill women now had an incentive to take care of them. Furthermore, the Finance Ministry has also issued a directive that apart from the reservation in government sector even the private sector should employ persons with disabilities.[11] In February 2006, the government announced the national policy for persons with disabilities.[13] A specific focus has been given to the problem of mentally ill persons in this policy. Of special note, is a provision for women who are disabled and suffering from a mental illness, to be given assistance to look after their children. The Ministry has also been encouraging district level Panchayati Raj institutions in setting up of mental health care homes for mentally ill persons with the involvement of NGOs. Alternatively, family support groups are also to be encouraged in setting up custodial care institutions for persons with disabilities who are without community or family support. Measures are also to be undertaken at the village level to set up residential rehabilitation centers for providing vocational and social skills to the affected population.

The policy makes a special note of women with disabilities and states that as per the 2001 Census, there was 93.01 lakh women with disabilities, which constituted 42.46% of the total disabled population. The policy noted that women with disabilities required protection against exploitation and abuse and made the following suggestions. Special programs will be developed for education, employment and providing of other rehabilitation services to women with disabilities keeping in view their special needs. Special educational and vocation training facilities will be setup. Programs will be undertaken to rehabilitate abandoned disabled women/girls by encouraging their adoption into families, support to house them and to impart them training for gainful employment skills. The government will specially encourage those projects where the representation of women with disabilities is ensured at least to the extent of 25% of total beneficiaries. Steps shall be taken to provide short duration stay homes for women with disabilities, hostels for working disabled women, and homes for aged disabled women. It has been noted that women with disabilities have serious difficulty in looking after their children. The government will also take up a program to provide financial support to women with disabilities so that they may hire services to look after their children. Such support will be limited to two children for a period not exceeding 2 years.[13]

The Gitanjali Nagpal media report led to a Delhi University student filing a Public Interest Litigation to draw the court's attention towards the plight of the mentally ill homeless women in the capital.[14] In response, the Delhi High Court asked the government to set up special wards for the mentally ill women, especially the homeless, in the state government-run Nirmal Chhaya shelter homes within 3 months. These special wards were to have a team of a psychiatrist along with medical staff and all necessary facilities for the rehabilitation of the mentally ill. The High Court Bench also gave the following directives:

• The central government was to release funds for the Urban Health Module so that rehabilitation work can be done at a faster pace

• The Judicial Academy was to sensitize the police and judicial officers about the issue

• The government was to set up an authority for mental health, and the Delhi Development Authority was to provide land to the government for the purpose

• The government was also to constitute a committee comprising of the secretary of the social welfare department, principal secretary of family and child health development, and the head of Department of Psychiatry at the Institute for Behavioral Health Studies and Applied Sciences and asked it to submit a compliance report

• The government was to formulate guidelines so that people could help the mentally ill without any legal tangles.

In the same year, the National Commission of Women (NCW), on the eve of International Women's Day, conducted a seminar cum workshop which attempted to address the issue of mentally ill women, their homelessness and generate solutions for this complex problem.[15] Speaking at the seminar NCW Chairman, Girija Vyas said that India is home to 5 million mentally ill women of which nearly 1,000,000 need long-tern rehabilitation. The salient features of this seminar were discussions on quality of care in institutions and de-institutionalization and de-custodialization, followed by a session on how to cull out relevant points in the legal framework, and suggest filling up of lacunae in law and reformation, where-ever it is warranted. Another session dealt with homelessness among mentally ill women and how public sensitization and community initiative can go a long way in improving the plight of such women.

Participants for this seminar had representatives from all spheres of life and included medical professionals, legal fraternity, and NGOs. The current status of rehabilitation for mentally ill women was found to be grossly inadequate. Apart from a dearth of services and staff, the quality of the existing ones was also deemed to be poor. The number of halfway homes was insufficient, and there was no provision for essential care facilities. There was no communication between the different bodies like the Ministries of Health and Family Welfare, Social Justice and Empowerment, Law, Women and Children, State, and National Women Commission, etc. The absence of any monitoring committee to aid communication between these bodies further aggravated this problem.

In this chapter, the deliberations of this seminar will be elucidated under relevant headings of gaps in knowledge and care, legal loopholes, and future directions.

CONTRIBUTION OF VOLUNTARY AGENCIES

As mental health has received a much-delayed attention from the government in both policy matters as well as budgetary allocation and things have been looking bright only in the past 5 years plan, much of the meager rehabilitation services available, with those for women being scarcer still, were largely taken up by voluntary agencies. Be it the involvement of consumers and their families, a media report or witnessing an appalling event, all these have been the sparks that have spurned people to exemplary action in the field of psychosocial rehabilitation of women. A few of these voluntary agencies are worthy of mention here.

Pioneering the psychosocial rehabilitation services into a hitherto unexplored territory of the mentally ill were the Bengaluru based Medico-pastoral association and the Richmond Fellowship Society - India (RFS-I) Branch.[16,17] Both these societies started half way homes based on the “therapeutic community” concept and have acted as role models for similar organizations in the past two to three decades of their existence. The RFS-I is an affiliate of RF International, UK, which is one of the largest NGOs working in the field of mental health and operates in more than 30 countries worldwide. Apart from imparting training in the field of psychosocial rehabilitation it has since its inception in 1986, established four centers at Bengaluru, New Delhi, Siddlaghata in rural Bengaluru and Lucknow. After its successful maiden venture, “Vikas” a half way home exclusively for men, RFS in 1989 established “Accredited Social Health Activist (ASHA)” a center for both male and female residents.[16]

There have been many other organizations which have sprung up in the past two decades, but they serve a small minority of the needy. Among them, notable for their specifically women-oriented rehabilitation work are examples of three different voluntary agencies. Paripurnata, a halfway home for mentally ill women was established in 1992 in West Bengal by a gynecologist, Dr. Joyce Sirimoni, after a news report drew her attention to the plight of female noncriminal lunatics languishing in jails.[18] With the help of other like-minded individuals, she started a halfway home for these mentally ill women. A committee appointed by the Supreme Court of India in response to a Public Interest Litigation, to investigate the issue of mentally ill persons detained in prisons, recommended that the approach of Paripurnata be accepted by the State Government as a model for further replication. Paripurnata was then just 3 months old. Not long after, the Supreme Court passed a final verdict against the detention of mentally ill persons in penal institutions.

If Paripurnata was conceived by a health care provider, caregivers Anjana and Mukul Goswami, who had personally experienced the difficulties of rehabilitating a family member suffering from schizophrenia, founded “Ashadeep” at Guwahati in 1996.[19] Compared to Kolkata and West Bengal, the psychiatric services, both clinical and rehabilitative were abysmal in the North East, and Ashadeep sought to provide post clinical rehabilitation services for the mentally ill. The experiences as a caregiver at the individual family level led to the conceptualization of each of Ashadeep's programs, and initially the services were limited to serving the mentally challenged individuals coming from families. But as new needs arose, new programs evolved from an already existing program, based on what was felt was required at the community level. And in 2005, Navachetana, a home for homeless mentally ill women, was started in an attempt to rehabilitate those lying untended on the streets of Guwahati and to re-integrate them with their families.

Navachetana, through the support of Sir Ratan Tata trust, started out as a shelter capable of supporting 20 residents, but reasonably positive outcome of this venture, led to the residential facility of being expanded physically and qualitatively into two components - Navachetana Transit Care and Navachetana Rehabilitation Home. Not limiting itself to just rehabilitating the homeless mentally ill, the organization also seeks to ensure that homelessness is prevented and attempts to do so through a free psychiatric outdoor clinic at Guwahati and 2 monthly outreach programs in two other districts of Assam. Ashadeep also started humbly but has grown from strength to strength and the conceptualization of new programs to address freshly emerging needs is an example of how an acorn has grown into a mighty Oak.

In yet another part of India, an obviously mentally ill woman, half-naked and with matted hair, dashing into the traffic in Chennai in 1993, instigated two young social work postgraduates, Vandana Gopikumar and Vaishnavi Jayakumar into forming “The Banyan” a halfway home for mentally ill homeless women.[20] When their attempts to admit the woman, who was in desperate need of medical and psychiatric attention, were met with reluctance from mental hospitals and NGOs, the 23-year-old developed The Banyan as an NGO, serving Chennai's homeless women with mental illnesses. To start with, the organization rented a three-bedroom building to run a care and rehabilitation center, named Adaikalam (Tamil for “home”).

Since 1993, The Banyan has reached out to more than 1500 women and reunited around 850 women with their families all throughout India. According to The Banyan's website: “Although The Banyan offers a comfortable home to women in distress, it is important to remember that The Banyan is not an institution for lifetime patients. The ultimate goals of the project being rehabilitation and empowerment, The Banyan is an effort to reunite the women with their families and to help them reintegrate back into the mainstream society to be able to lead normal lives again.”

Their experiences at Banyan have evoked both controversy and appreciation from the public. Traditional communities in Indian society do not generally accept the unexplained absence of their female members for any length of time, the place of the woman being either behind the veils of the purdah or in the confines of her parents’ or husband's house. The “problem community” for rehabilitation purposes has generally been the Indian middle class, where the concept of a woman's place still seems to hold strong. At The Banyan, it's been observed that communities with a lower socioeconomic status are generally more accepting to returning residents, due to a different moral code and difference in beliefs and rituals. These attitudes have helped so many recovered women unite with their families all over India and led to many happy reunions, overwhelming as they are when a long-lost member of the family, thought to have no hope in life, walks back home “reborn.”

The functioning of The Banyan, which is detailed below, serves as an example for other agencies wishing to involve themselves with the psychosocial rehabilitation of women. A person is referred to the Banyan through an individual, a volunteer, or the police. A social worker and a health worker from the Banyan then go on a rescue mission and bring the client to Adaikalam. The basic needs for food and hygiene are taken care of and enquiries are made for details of the person's family and place of residence. If the lady has a family to look after her, she is relocated to her family home. However, if the person has no family and is found to be mentally ill, a Reception order is received from the police and the resident is admitted to the transit home. The case is then assigned to a social worker who starts her case documentation and the resident then receives her first psychiatric evaluation and medication. Next the social worker carries out psychological, physical, social and skills assessment and an individualized treatment and rehabilitation plan is chalked out along with the resident.

The above mentioned examples of Paripurnata, Navachetana and The Banyan, prove that all the stake holders, from the service providers, to the consumers and their families and then society at a large can and should be a part of the rehabilitation strategy to make it effective and meaningful.

WHY DO WOMEN REQUIRE SPECIAL REHABILITATION EFFORTS?

Social consequences such as homelessness, vulnerability to sexual abuse and exposure to HIV and other infections contribute to the difficulties of rehabilitation of women. The absence of any clear welfare policies in this part of the world for this group of women and the social stigma further compounds the problem. The following points make special rehabilitation efforts for women imperative:

• Stigma being more towards mentally ill women as well as women caregivers, denial of educational and occupational opportunities, denial of access to appropriate health care, a gender bias in diagnosing mental problems influenced by cultural expectations and stereotypes of what is normal behavior for men and women, are all factors that may lead to the illnesses going untreated and becoming chronic

• Furthermore, the impact of mental health problems also shows a gender differential. For example, whereas women were required to be the primary carers if their husbands were mentally ill, it was their own families that were responsible for their care if they were to become ill

• Although the prevalence of chronic psychotic illnesses such as schizophrenia and bipolar disorders in women may be less than that of depression, anxiety and related conditions, they pose an immense problem in management and rehabilitation. Their propensity to be chronic, sometimes unresponsive to treatment, the resultant disability in various aspects of functioning, and above all, the stigma attached to these illnesses and the social sequelae make it a public health issue, notwithstanding the smaller numbers.[21,22]

The Schizophrenia Research Foundation at Chennai, India carried out an ethnographic, qualitative study of 75 mentally ill women who were separated or divorced.[23] It was found that all but eight of these separated women lived in their parental homes with the onus of care being borne by the aging parents. The legal separation had occurred only in 16 cases, all of them being educated women. None of them remarried while 34 of the husbands had done so. The fathers looked after only six of the 26 children. This study sharply brings into focus some issues, which confront women in many developing countries. They are:

• A lack of awareness of the illness and its disabilities resulting in a widespread belief that marriage is a panacea for all ills. This resulted in the parents of the ill women arranging their marriages, very often suppressing the fact of mental illness from the husband and his family

• The absence of legal protection including maintenance for such women

• The burden of care of these women goes back to the parents, many of whom are aging and themselves sick

• Lack of any state-managed programs, which will offer some kind of physical, sexual and financial security for such women

• Negative attitudes of the husband and his parents and sometimes even the extended family hastened the process of separation and sometimes desertion.

Thus, special rehabilitation efforts would need the backing of policy planners as any comprehensive strategy to improve the mental health of women necessitates coordinated action. This involves improvement of policies and legislation, better access and availability of health care facilities, better health education, and determination of safety at the places where women live and work. Enhanced gender sensitivity in all walks of life will certainly augur a better future for the mental health of women.

RANGE OF AVAILABLE PSYCHOSOCIAL REHABILITATION SERVICES

Regarding service delivery mechanisms, significant developments have taken place over the past two decades. These are the development of halfway homes and other measures like day-care centers by nongovernmental agencies for rehabilitation services, which are in keeping with the local sociocultural context in different countries. These facilities vary in terms of intake criteria of patients, philosophy, and management techniques. Depending on the location of the patients, their access to services and the location of the patients, their access to services and the resources available to the family, rehabilitation can be carried out in different settings.[24] These are as follows:

Day care

Day care services are largely concentrated in the urban areas. They are run by governmental and NGO sectors. Overall, the experience of different models of day care in government and nongovernmental sectors has been promising as they are based on low cost, with family involvement and people's participation. These models are replicable and can be managed by family members or trained volunteers. Women can be engaged in gender-sensitive vocations like handicraft making, food processing, etc.

Residential rehabilitation

Halfway homes based on the therapeutic community model facilitate a gradual integration for those who are fit for discharge from hospitals but are not yet capable of living with their family or independently in the society. For homeless mentally ill women, who are vulnerable to physical and sexual abuse, these homes function as safe shelters while also providing vocational training and initiating a process of integration with the family. Most of the halfway homes are the ventures of voluntary organizations and though they have brought about a significant change in the lives of their inmates, these services need to be consistently duplicated in various settings if the silently suffering majority is to be benefited.

Home-based rehabilitation

Though this is necessary in the case of patients who are confined to their homes and are unwilling to move out, there is not much of a guideline as to how this can be achieved in a structured fashion. But as a large percentage of our patients with chronic mental illnesses continue to live with their families who also bear the brunt of stigma and discrimination, there is an urgent need on developing programs on this front.

Community-based rehabilitation

It has been widely recognized that in the face of limited manpower and fiscal resources, community-based rehabilitation (CBR) is the most satisfactory strategy for dealing with chronic disabilities, including mental illnesses. A study done to evaluate CBR for chronic schizophrenia in rural India has produced preliminary evidence that it is a feasible model of care in resource-poor setting.[25] While CBR may be initiated and established by mental health professionals, this program should be run with minimal professional inputs and maximal community involvement and participation. Some institutions in the country have instituted CBR programs, which is a promising strategy in the long run.

The components of psychosocial rehabilitation are multi-pronged and include:

• Social skills training, this includes problem solving and communication skills training

• Family psycho-education and behavioral family management

• Cognitive remediation, enhancing attention using behavioral interventions

• Vocational rehabilitation

• Combined psychosocial and drug therapies.

The overall result of such a comprehensive approach is that patients not only improve as a result of medication, but also recover their self-esteem and become more confident of their place in society as they gain proficiency not only in taking care of themselves, but also in their interactions with their family members and society. Reintegration into society is the ultimate goal of all rehabilitation.

GAPS IN KNOWLEDGE AND CARE

Most of the rehabilitation efforts and policies in India are in the field of physically disabled and it is only recently that the psychiatrically disabled are receiving any attention. Furthermore, the Rehabilitation Council Act of India, 1992 makes no mention of the psychiatrically disabled and is confined to those with visual, hearing, or locomotor disability or to those with mental retardation.[26]

The MHA, 1987 gives explicit directions regarding the licensing of mental hospitals and care of the acutely ill but does not mention guidelines for setting up rehabilitation services especially for those who are chronically ill.[10] Since the former require medical professionals, while the latter are seen to work well with voluntary workers even, as seen in the case of Paripurnata, there is a need to have a separate licensing and policy for setting up rehabilitation centers.

Apart from the lacunae in setting up rehabilitation services, there is also a lack of knowledge about which type of rehabilitation service work best. Since most of the work has been done in western populations, applying their knowledge to a vastly different cultural set up like that of India would be foolhardy. We thus need to create our own brand of services and improvise on them.

Most of the rehabilitation centers in India offer vocational training first and the client has to then seek employment, whereas data from the West, has shown that supported employment programs which work on a “place and train” paradigm are more effective than “train and place” practices when it comes to rehabilitating people with psychiatric disabilities.[27] Apart from setting up such “place and train” services, the evidence is also required on how best individual placement and support model of supported employment would suit the Indian scenario. For example, the food processing, garment, and handicraft industries provide ample opportunities for experimenting with the “place and train” services. How best the corporate sector or public-private partnerships can be involved in such rehabilitation efforts, has also to be worked out. Besides this, the potential of home-based industries and self-help groups of women, especially those in rural India, in helping the mentally ill woman reintegrate back into the society needs to be explored, documented, and advertised.

LEGAL LOOPHOLES

A survey of the relevant laws has shown that The MHA 1987 contemplates either institutionalization or nothing, as it talks only in terms of entry or exit from the mental hospital. Thus, an exit from the hospital requires that a patient be declared as “cured” and that the family is willing to take the patient back. In case of females, they are more likely to languish in the hospitals for a longer period unless they are “cured.” Families are less willing to take back mentally ill women and these inmates receive lesser visits as well. There is no provision in the MHA wherein the patient can be discharged from the hospital to lower community services, which needs to be amended.[10]

The other important observation is that institutionalization of women in mental hospitals is done not for the purposes of treatment but rather for procuring the evidence against her. Such evidence is then employed against the women in depriving her of her property, in divorce proceedings or denying her in obtaining custody of the children. Thus, there needs to be an amendment so that “Proceedings under the statute need not be used as evidence anywhere else.” This would serve a twin purpose. First, it would ensure that civil rights of the mentally ill persons, like matrimony and child custody, are not denied to them purely on the pretext of their illnesses. Secondly, mentally ill women can then access treatment without any inherent fears that this could be used in denying them their civil rights.

FUTURE DIRECTIONS

In the seminar conducted by NCW, the working group laid down the following goals, which should be the prescribed standards, to be met through legislative, administrative and personal intervention.[15]

• Up-gradation of the quality of care and service, and staffing

• Urgent need for deinstitutionalizing the patients-the process should be carried out in a phased manner in order to prevent the women ending up as destitute

• Smooth transition from one stage to the other in the medical cycle of the patients: Family→Institute/Hospital→Halfway home→Family

• An effective monitoring system to be instituted.

To bridge the gap between “what is” and “what ought to be” the following recommendations were made:

• NHRC report to be used for identifying the extent of implementation and persisting gaps and using suggestions made in it as guidelines for undertaking corrective measures

• Each link in the smooth transition of patient from Family→Institute/Hospital→Halfway home→Family to be elucidated and the complex needs of the patient to be met not solely by medical assistance but by the combined efforts of government, family care and support and guidance and assurance by the NGOs

  • Family→hospital/institute:
    • Gender sensitivity to be introduced so that female patients are not neglected and prompt treatment is initiated
    • Admission in hospitals to be encouraged to prevent illness taking a severe form
    • Different types of facilities to be developed, for example: Short stay homes for those requiring a brief period of crisis intervention during flare up of symptoms
    • A life cycle approach to be adopted during the treatment, for example: Nursing mothers to be provided special facilities for the care of the child
    • More social workers and NGOs to be attached to the hospitals to function as a constant bond between the professionals and family members so that the patient reaps the maximum benefit.
  • Institute/Hospital→Halfway homes:
    • This stage to be handled with utmost care as it forms the foundation of reintegration of the mentally ill woman back into the society
    • Patient to be imparted skill which ensures that she is not alienated from the society
    • Rehabilitation centers to be more gender sensitive in their programs and imparting of skills. Female oriented activities like stitching, weaving, embroidery, handicraft making and food processing etc., to be encouraged.
  • Halfway homes→Family:
    • NGOs/rehabilitation centers to ensure that the family understands the patients’ future needs
    • As in the present scenario, medication adherence is inconsistent and relapses go unreported, an attitudinal shift to be effected in the family and families to be advised to report back as early as possible, should a relapse occur
    • Parents of unwed girls to be advised against “hiding” mental illness from eligible spouses and hastening wedlock, as they could then end up with added misery
    • Females in the reproductive age group to be given appropriate counseling
    • Post-discharge monitoring by the case worker to be made essential.

• Continuous involvement of the family to be recognized as the key to de-institutionalization

• Encouragement of private sector by providing incentives for setting up rehabilitation centers

• Effective co-ordination between different Ministries of the Government that is Ministries of Health and Family Welfare, Social Justice and Empowerment, Law, Women and Children, Labor, and Education, etc

• State commission for women to play an active role in monitoring state-run institutions

• Active networking between all sectors with a monitory committee supervising and ensuring communication to be made essential

• Dual licensing policy to be done away with for procedural simplification

• Encouragement to be given to self-help groups and consumer movements

• Existing laws which are likely to contribute to the destitution of mentally ill women to be reviewed, so as to protect their civil rights

• Setting up of a few centers with vocational training facilities for women who otherwise have no other shelter

• Short-term training programs in psychiatry to be encouraged

• A comprehensive “rehabilitation policy” to be evolved by the government to help in the integration of patients back into the society

• Public awareness about mental illness to be taken up on a war-footing with aggressive media campaigns so that symptoms of mental illness are recognized early, and myths and misconceptions about them are gradually dispelled.

Apart from the recommendations made in the above-mentioned seminar, the following suggestions should also be taken into consideration. Given the magnitude of mentally ill women who require rehabilitation and the meager resources available to counter this need, it would be wise to remember that a “one size fits all” approach would not be appropriate. Not all mentally ill women require the same extent of rehabilitation services and neither would all of them be able to achieve the same level of functionality. Thus, the milder cases might not require extensive services while the more severe ones might not benefit from them. Just as there is no single treatment regimen for all patients, there cannot be one single rehabilitation package. The needs of each individual have to be recognized and dealt with accordingly.

A thorough, structured assessment for identifying the areas of rehabilitation provides a roadmap for future progress as well as a baseline for monitoring it. One example of an interview-based, structured assessment is the Client's Assessment of Strengths, Interests, and Goals.[28] It comprehensively evaluates the quality of life, unacceptable community behaviors, side-effects of medication, functional living skills, medication adherence, and compliance. Thus, starting rehabilitation efforts without an assessment would be like setting sail without any navigation charts.

Conventionally the terms “treatment” and rehabilitation refer to interventions that differentiate pharmacologic from psychosocial services, that are relevant for different phases or types and severity of mental disorders, or that focus on different goals or behavioral dimensions. It is imperative that treatment and rehabilitation are considered as seamless approaches to caring for the same human beings who require different interventions for different problems at different points during the course of their disorders.[29]

The system of ASHA started by the government as part of the National Rural Health Mission, by which young women in the rural areas are trained to take care of the ill in the local areas, needs to be expanded to serve the mentally ill. While the government seems to have taken some steps in the right direction, a lot depends on sustaining them. Apart from the service providers, the service users, their caregivers and families have an important role in improving services. Stakeholders should assist in generating social support, building of local resources and providing external resources when needed. The user movements have to be actively engaged in bringing about changes in attitude towards the mentally ill women.

To conclude, the mentally ill women are but a substrate of women in general.

As the World Health Report says, “Women's health is inextricably linked to their status in society. It benefits from equality and suffers from discrimination.”[30]

The complex problem, not only of rehabilitation but also that of women's mental and physical health care can be addressed only through sustained programs of education and awareness generation and improving the infrastructure for service delivery and care.

As women are an integral part of the society and cannot live in isolation, care for them too cannot grow in isolated spheres. Psychosocial rehabilitation of women is a part of the overall rehabilitation services available to the psychiatrically ill, which in turn needs to be an integral part of the mental health services of any institution or nation.

SUMMARY

Care for the mentally ill has moved out from the custodial settings in most part of the world but in some instances has led to the proverbial “from the frying pan, into the fire” fate. Not preparing both the mentally ill person and the community for re-integration might lead to the patient ending up on the streets. And if the mentally ill person happens to be a woman, then the vagaries of fate can be harsher still. It is here that gender sensitive services become imperative. This article discusses in brief, the global and Indian scenarios of rehabilitation of the mentally ill women and goes on to detail the contribution of the state and voluntary agencies in this regard. It explores why women require special rehabilitation services and the existing range of services which are currently available. It notes the gaps in knowledge and care as well as the legal loopholes which act as obstacles for women receiving good quality care. In conclusion, it elaborates on the future directions which need to be taken to travel from “where we are” to “where we ought to be.”