“Homeless people in Chennai do not want to come with me,” says Nandhini, a social worker working for the Hope Charitable Trust in Chennai. “I have been spit on, verbally and physically abused by people going through a mental health episode when I approach them and ask them to come with me to get proper treatment. There are many stories I can tell you where the same people later became my friends when they got help and got better,” says Nandhini.
Nandhini reminisces about the time when a girl named Priya from a well-to-do family in Chennai was rendered temporarily homeless because of severe depression. She was in love with a man from another religion, and her parents disapproved of it. Priya ended up on the streets when she suffered from a mental breakdown because of her break up with the man, and her parents didn’t know how to take care of her anymore.
“Priya’s case is an example of how even well-educated people in our society can lose everything due to mental illness.”
Getting adequate mental health attention for the urban poor who face a great deal of neglect is even more of a challenge. Mental health care remains a stigmatised topic in many spheres, even in large metros such as Chennai.
Mental illness treatment in Chennai is exacerbated by the fact that it might be prohibitively expensive for the majority of the city’s population. Mental health treatment gaps ranged from 28% to 83% in the National Mental Health Study (NMHS), 2015-16, survey results.
An estimated Rs. 1,000-1,500 a month is spent by families on treatment and travel to get care for persons with mental illnesses, according to the National Mental Health Survey (NMHS) (2015-16). Expenditure for mental health care often put families in a difficult financial position, according to the survey’s participants.
Chennai has several organisations that work for the benefit of the poor in dealing with their mental health.
Schizophrenia Research Foundation (SCARF) India is a nonprofit mental health centre in Chennai that provides a complete spectrum of multidisciplinary psychiatric treatment and rehabilitation services.
Dr R Padmavati, Director at SCARF, says, “We deal with individuals with a range of mental disorders from the spectrum of child and adolescent mental health to elderly people with dementia. In addition, we also deal with people with serious mental disorders, such as schizophrenia, bipolar disorders, chronic disorders such as anxiety disorders, and chronic depression.”
Reducing apathy through proper mental health care
Getting the urban poor to accept mental healthcare in the first place is a huge challenge. The desire for change should come from the mentally ill people themselves, and that’s why social workers and doctors at organisations try very hard to convince mentally ill people to go on their accord to the organisation.
Nandhini says, “If I put on my corporation uniform and come with a van, those with mental illnesses are intimidated by it. We convince them to come with us by offering good food and good living conditions, but people with severe psychosocial difficulties often refuse to come to the organisation.”
Mentally ill people can oftentimes be apathetic to their dire living conditions and can give up hope of a better life. The apathy frequently lasts for a long period. People may lack the motivation to engage in activities that require them to think or feel.
Mental health illnesses are generally stigmatised in society, causing mentally ill people to leave their families. This can happen for two reasons: the mentally ill individual’s family may refuse to care for them, or the mentally ill person may leave on their own.
Nandhini says, “It’s quite disturbing when a mentally ill person runs away from home because it means that they won’t stay in the same place for more than a few days. It becomes very challenging to care for them when they are in that headspace.”
Need for mental health interventions in Chennai
Dr Padmavati stresses the importance of psychosocial intervention in terms of treating mental illnesses. Psychosocial therapies have been shown to improve the functioning of patients. There is a strong link between psychosocial therapies and fewer relapses and hospitalisations in people with schizophrenia.
Another mental health organisation in Chennai, The Banyan, strives to increase awareness of mental health and support its practice in all aspects of society. The Banyan has been a vital link in the chain of treatment for persons with mental illness in Chennai since 1993.
Banyan uses a methodology that combines medicine and rehabilitation, including psychiatric treatments, vocational training, occupational therapy, and community reintegration.
If an individual has problems with self-care, there are techniques by which psychiatrists and social workers train them to improve their self-care, such as maintaining personal hygiene. If they have a problem with social interactions, organisations will offer social skills training and communication skills training.
Preetha Krishnadas, assistant director at The Banyan, says, “These are simple strategies that we can implement, and people do improve in these areas. So, one of the important things is motivation. You know, most people lack motivation in trying to take care of themselves, not interact with people, and do simple basic survival skills activities. So, motivation is the foundation, one of the foundations in which most of these strategies are designed.”
Dr Padmavati stresses the importance of cognitive interventions for mental health. Cognitive intervention is a sort of psychotherapy treatment that teaches people how to recognise and modify harmful or distressing thinking patterns that affect their behaviour and emotions.
Cognitive-behavioural therapy focuses on modifying automatic negative thinking that can exacerbate emotional problems, sadness, and anxiety. These irrational negative ideas hurt one’s mood. CBT identifies these thoughts, challenges them, and replaces them with more objective, realistic ones.
Dr Padmavati says, “Mental illness is often associated with deficits in attention, concentration, information processing, memory, and so on. So, unless all those improve, improvement in other functioning can be delayed. So the two conditions where social skills interventions are implemented are psychosocial interventions, and two is cognitive interventions.”
Sometimes many patients automatically see improvement through the implementation of these two interventions.
Gendered stigmatisation in mental health in Chennai
Mental illness is also gendered. In many cases, women suffer the most since they bear the brunt of marginalisation on two counts: one, based on their gender and then again because of their mental illness.
Men and women seeking psychiatric therapy at healthcare facilities in India report equal levels of depression, according to an Economic and Political Weekly (EPW) report, although women report greater perceived stigma. Social and cultural variables, such as the level of stigma associated with specific symptoms, impact how people perceive and report discomfort in psychological or somatic terms.
In the case of women, the stigma stems from the idea that being diagnosed with a mental disorder could jeopardise one’s marital chances. Fear of rejection and the urge to hide sickness from others are two of the most common stigmatising experiences reported by Indian women.
Dr Padmavati says, “There have been cases where the woman’s mental disorder is concealed by the family during her marriage, and later, she is thrown out of her husband’s home. But in the case of a man being mentally ill, society treats him differently. The woman is expected to stay with him, especially if she comes from a low-income family and doesn’t have any option to go back to her family.”
Community-level initiatives hold key.
In 1988, SCARF did an experiment where they used community-level workers in rendering psychosocial interventions or community-based interventions for people with mental health disorders in underserved communities. It was a huge success, and subsequently, SCARF implemented the model of mental health services being rendered by community workers in several different parts of the country.
Community-level initiatives work wonders at reintegrating mentally ill people into society. Dr Padmavati agrees that the strongest foundation for any community mental healthcare is not the psychiatrists but the community-level work done by social workers in the field.
“It is our community-level workers who are the most powerful members of our team. They are the ones who connect with the families, convince the families of medical care, convince them of opting for psychosocial interventions, and actually deliver psychosocial interventions,” says Dr Padmavati.
The use of mobile telepsychiatry to deliver therapy has been a notable SCARF breakthrough. A total of seven districts were covered, with a total population of 5.2 lakhs. A custom-built bus that goes across regions and is equipped with the essential communication technology for consultations with a psychiatrist at SCARF in Chennai.
The bus pharmacy provides free medication based on the doctor’s prescription. Community workers assure follow-up by keeping electronic records. Such models can be scaled up effectively across different settings to make mental healthcare more accessible and less daunting.
Preetha from Banyan agrees that community reintegration is very important for people with mental health disorders. She says, “Lack of support system or lack of understanding of the person becomes an issue, and this is when they are socially isolated. So often, even the family members will not take them to any social gatherings or even in the neighbourhood, people won’t talk to them. So they experience social isolation, which creates the social stigma that is demeaning to a mentally ill person.”
One person, usually a social worker, will be present to listen and chat with them in order to form a support network. This one person who is actually working with them will create a support network in the local community that will function because the safety circle, or safety net, is extremely important for those who are dealing with mental health concerns.
It’s not the advanced level of mental healthcare that is required in most cases. Oftentimes, the simple process of communication between the community workers and the people of their community works like a charm for the rehabilitation of mentally ill people.