Completed research studies:

A STUDY OF THIRTY REINTEGRATED CLIENTS OF THE BANYAN

IN SOUTH INDIA

BY

Gayathri Balagopal and Chaitali Shetty

The study has attempted to understand access to mental health care in the context of socioeconomic deprivations of clients (homeless women with mental illness) of The Banyan (a licensed psychiatric facility) who were reintegrated with their families in three South Indian states—Tamil Nadu, Kerala and Andhra Pradesh. The Banyan is a licensed psychiatric facility, to treat homeless women with mental health issues and governed by the Mental Health Act 1987. The Banyan follows a sociomedical approach— psychological therapy, psychiatric treatment, occupational therapy and vocational training in the admission, treatment and rehabilitation of homeless female clients with mental health issues. Reintegration of the women with their family or independent living in the case of women without families is the prime goal of The Banyan. Since The Banyan’s inception in 1993 nearly 1000 women have been reintegrated with their families or have moved into the community living setting of The Banyan. This study has focussed attention on the social context of mental health and access to mental health services among the clients of The Banyan who were reintegrated with their families. While the sample size does constrain us from generalising, there are some important findings which indicate a need for reorientation on strategies to address the needs of homeless women with mental health issues. The findings attest to the need for developing strong linkages with other organisations (government as well as non governmental) for the provision of follow up treatment and rehabilitation services, as only one-third of the clients (33.3 per cent) visited a health facility for treatment. The IDEAS Scale scores show that around half the clients (53.3 per cent) suffered from mild disability, one-fifth (20 per cent) from moderate disability and about one-fourth (26.7 per cent) from severe disability, indicating the need for rehabilitation services. Information on average duration of illness (11.4 years) reveals the long term nature of the disease among the reintegrated clients, which requires long term care from the health system and family members. Clients who are severely disabled are vulnerable to neglect, as carers (who are inevitably females according to the literature on care giving) face competing demands on their time from other family members in addition to household work and in some cases, paid employment in the work force. Access to respite services for the carers is an important dimension of this issue—facilities like day care centres are important support services that the family needs to continue to care for the client in the community setting.

Among the clients who accessed health facilities for treatment, close to three-fourth (70 per cent) utilised government health facilities, highlighting the important role of public sector provision of mental health care in enabling access to vulnerable categories. Severe disability and relapse are more common among clients belonging to the age group 45-59 years and 30-44 years, who are widowed, living in households headed by their adult children and spouse, who are illiterate and are economically inactive. Further, treatment seeking displays a social gradient—a relatively large proportion of those in the 45-59 years age group, married clients, illiterates and those without access to income generating work were not treatment compliant suggesting the crucial role of social context in influencing access to mental health care. It is evident that for consistent compliance with treatment, it is necessary for clients to have access to localised sources of psychiatric treatment, which requires effective implementation of the District Mental Health Programme through the Primary Health Centres and networking with other non-governmental organisations in the provision of care. Discharge from institutions does not just mean a change in the locus of care—it has to be accompanied by localised access to mental health care services and reintegrated clients and their families have to be aware of the need for compliance with treatment and availability of mental health services in the community; attention to the gendered nature of deprivations has to be addressed by the government, failing which there is a likelihood of reversal of the successes of treatment. Public policy has to incorporate the rehabilitation requirements of persons with mental illness, as treatment addresses only the symptoms and not the disability. Access to an independent source of income is critical for the clients, especially women, as families cannot cope with the burden of care, leaving the client vulnerable to neglect, increased severity of illness and at risk of homelessness—in the case of clients with severe disability it is crucial that the government recognises their pension entitlement to protect them from absolute destitution and neglect. Prescription for well being of clients who are discharged from mental health institutions has to go beyond health interventions and focus on comprehensive interventions that address socioeconomic deprivations and requirement for rehabilitation services for the client and respite services for the family.

A study of thirty re-integrated clients of The Banyan in South India

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Disability Allowance of The Banyan. A study on re-integrated clients and their care givers.

By Dr. Lakshmi Ravikanth & Mirjam Dijkxhoorn

This study investigates the impact of a disability allowance (DA) programme of the non-governmental organization The Banyan in collaboration with the Sir Ratan Tata Trust (SRTT) on re-integrated clients with mental illness and their care givers.

Need of the study

While the primary purpose of ensuring attendance to OP was established by the regularity of re-integrated clients and their care givers coming to monthly reviews and receiving DA, the need was felt to investigate incidental benefits of the DA in quality of life of the re-integrated clients and family burden of care givers.

Aims of the study

1. To find out how DA has affected the quality of life of the re-integrated clients.

2. To find out whether care givers of re-integrated clients face any burden in taking care of a mentally ill person.

Key Findings

Re-integrated clients (RC)

Most RCs felt that they could respect themselves and were respected by their family members, because they made a contribution to the household.
Social inclusiveness was reflected in the fact that many RCs reported to be able to attend social events because of the DA. The support group of The Banyan also provided an opportunity to interact with others and was mentioned as a social event.
Spending on children emerged as an important spending pattern. Contributing to children’s education was frequently mentioned as what the DA was spent on. One RC mentioned that she was able to organise a birthday party for her daughter, because of the DA.
RCs visited the OP mostly for DA and medication, which is an honest and clear purpose. Regular attendance of OP benefits RCs both directly, through the receipt of DA and incidentally, because it enables control of relapse, and psychiatric review contributes to knowing one’s own mental health well-being.
Multiplier effects were observed in some RCs aspiring to start a business with the DA amount. Quantifiable multiplier effects could be seen in savings, lending money to others, investing money or contributing to children’s education.
Receiving DA also showcased a personal and emotional positive spiralling effect, for example when the RC reported feeling good, which it in turn influenced the care givers and improved family life.

Care givers (CG)

Husbands constituted the majority of care givers (32%). This denoted a very health trend, since the husbands regularly attended the OP together with their wives and showed care towards them.
18% of the care givers were children, who are assuming responsibility. This shows reverse care giving. While at one level this seemed positive, the apprehension was whether care giving is at the cost of their education, employment and recreation.
The high unemployment rates amongst the re-integrated clients, combined with impoverished conditions of the family, indicated that re-integration of a client to the family imposed burden on the family resources, and increased care giver responsibilities.
Concerns about the future were present for almost all care givers, especially the question: “What will happen to my wife / daughter / relative when I am no longer around to take care?”
The health problems reported by CGs included sleep deprivation, pain in limbs, getting tired mentally and physically. One person reported distress and not able to eat properly, resulting in an ulcer. Taking care of the RC for some resulted in body pain due to old age.

Disability Allowance of The Banyan - a study on re-integrated clients and their care givers

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Self-Help group as an alternative model of rehabilitation of homeless women with mental illness - a case study of 2 SHGs of The Banyan.

By MADHU SHARAN

Summary

A conclusion drawn from the study is that formation of self-help groups is definitely a good ‘alternate’ model of rehabilitation of homeless women with mental health issues. However, for sustainability and replication, it would help if certain ‘add-ons’ could be kept in mind.

Introduction Homelessness and mental illness are serious issues by themselves, but when they combine the problem becomes larger, more complex and grave. Persistent reluctance to address these issues has turned them into an “invisible” problem largely unrecognised and therefore seldom discussed. Increasing incidence, however, has resulted in this problem assuming alarming proportions.

It is now largely accepted that homelessness is both a cause and consequence of mental illness and disability. Women’s mental health need to be considered in the context of the social, political and economic realities.

In addition to treatment and care of homeless women with mental illness, rehabilitation of such women is critical, both, for continued wellbeing of women and the socio-economic growth of society.

The Banyan has devoted itself to rescue, treatment and rehabilitation of homeless mentally ill women. The Banyan aims to reintegrate these women with their families and communities. However if, for some reason, re-integration is not possible, The Banyan provides alternate models of rehabilitating these women and bringing them back in the mainstream of social being. Organizing the socially marginalized women into self-help groups has been a part of strategic interventions in these situations.

This paper seeks to examine the hypothesis that high functional homeless women with mental health issues, who do not have the option of being re-united with their families, could be rehabilitated back into society by forming them into ‘self-help groups’ and offering them mentoring and monitoring support through an organisation, in this case, an NGO, The Banyan in Chennai, India .

This research study is based on case studies of 2 Self help groups (SHGs) of The Banyan namely, ‘Vizghudugal,’ and ‘Tulir,’ at Kovalam in Tamil Nadu in Southern India.

It seeks to examine whether, and to what extent, The Banyan’s model of organizing ‘high functional homeless women with mental health issues’ into ‘Self-help groups’ (SHGs) and building their capacities, has had an impact on their rehabilitation in mainstream society and /or increasing their level of empowerment. Further, it (the study) seeks to ascertain what additional features could be added to this model to make it ‘a more suitable’ model of rehabilitating women in similar situations.

These issues have been examined against the backdrop of philosophy, approach and service-delivery of The Banyan, as an organization as a whole, and analyzed specifically in the context of the design and implementation of ‘The Banyan’s SHG model,’ and the changes in the lives of the SHG women of groups promoted by The Banyan.

The study is unique as it seeks to link the philosophy of Self-help group as a model of empowerment promoted by international and national government and non-government organizations with the clients perspective of ‘empowerment’ and ‘rehabilitation,’ as experienced in the field through the intermediation of an NGO, The Banyan.

About the Study methodology The duration of this ethnographic field study has been for over two years i.e. since the inception of the 2 SHGs. Review of literature was undertaken on topics related to mental health, homelessness, Self-help Groups through websites, Govt. records, documents and publications, documents and annual reports of some NGOs dealing with SHG programmes in Tamilnadu, in particular. Additionally, the Prime Researcher’s association with The Banyan helped her to understand the nuances of homelessness and mental health along with the perspectives of the organization, staff and clients.

To interrogate, examine and trace the changes that have occurred in the women’s lives from homelessness to treatment and care to becoming member of a SHGs and independent living, both quantitative (to a very limited extent) and qualitative data have been used. Quantitative data has been used for economic aspect of SHG in terms of amount of savings of SHG members, interest rates, loans received from the banks and the uses thereof. Qualitative data has been used to understand, interrogate and develop a sociological understanding of whether there has been any expansion in women’s own sense of ‘space’ in terms of their rehabilitation in the community as a result of interventions by The Banyan.

Interviews, detailed focus group discussions and participatory method of data collection were used to interrogate and map the ‘ideas of change and empowerment’ of the 27 (in the age group of 20 –55) SHG women. They were interviewed both individually and at group level meetings. In-depth, personal interviews of 8 members.

Four staff members of The Banyan, across various levels, were interviewed to understand their perception of the SHG programme, vision, strategies of the programme, and plans for the future.

Interviews of indirect stakeholders like neighbors, members of the community, Panchayat leader, and tea-stall owner were also taken to understand their perceptions of mental health and The Banyan SHGs. Perceptions of the field workers were actively sought. Their comments and those from the community
Contributed to detailing and refining the questions.

The study has been conducted under 5 sections and summed up at the end with recommendations and a conclusion. The 5 sections are as follows:

• Section I deals with contextual background of the SHGs, member details, bank loans, and derails of training and expectations thereof.
• Section II details about the members views on SHG as a model and their support from The Banyan
• Section III deals with experiential sharing related to ‘social bonding’ and living together
• Section IV discusses issues relating to ‘stigma’ and their suggestions to combat it and
• Section V discusses views of the SHG members on the SHG model being an alternate ‘model of rehabilitation’ of homeless women with mental illness?

To the extent possible, voices of the women have been directly reported.

Conclusions and recommendations for sustainability and replication

Forming self-help groups of homeless women with mental health issues who were long term residents of the organization and being a companion in their journey towards independence and wellness is a challenging task and The Banyan needs to be lauded for its pioneering effort in this field. Women of both the self-help groups of ‘Vizhuthugal’ and ‘Tulir’ seemed to be brimming with energy, hope and confidence to make a success of their life and future. Social and emotional bonds among them were strong and the members were keen to work towards their economic and social empowerment. They shared a wonderful relationship of respect, trust and friendship with the Banyan staff and The Banyan, on its part, offered a tremendous amount of love, mentoring and monitoring support. It was heartening to see such close emotional and psychological bonds between members of an organization and its clients.

However, for sustainability and replication, certain add-ons could be suggested, which are the personal views of the author and not of the organization.

I. Training and Capacity-building: Due to the specific nature of the Banyan SHGs, the members would need continuous mentoring and therefore it was a good strategy to expose them to other Self Help Groups in Kovalam village. It helped them develop an understanding of the practical aspects of SHG functioning. However, for sustainability, a more formal, structured system of training programmes could be provided to the SHG groups, the way it has been envisaged in the ‘Mahalir Thittam’ model of Tamil Nadu Corporation for Development of Women (TNCDW). Additionally, it would help if The Banyan staff is also exposed to some kind of a structured training programme on various aspects of SHGs.

II. Sustainability of enterprises is a challenge to the SHG programme and it is no different in case of The Banyan SHGs. Customized skill training, product design, enterprise promotion and enabling marketing linkages needs to be a continuous engagement in the first two years of SHGs formation for sustainability in the long run. After adequate training and linkages on enterprise promotion, the SHGs could be encouraged to be on their own albeit gradually. However, during the process, effort should be also made to strengthen community linkages so that the organization could phase off gradually while being assured of SHG’s independence and well-being. Continuous engagement with the community would also help to reduce the stigma associated with the illness and ensure social and psychological well being of the SHG members.

III. Well-being: Speaking of well-being, it is important that SHGs of women with mental health issues continue to access treatment and care to maintain their wellness. It is therefore advisable that apart from routine medical check-up from the organization, a doctor /nurse /ANM /aaganwadi worker from the nearby PHC /community could also be trained on mental health so that the organization could leverage available infrastructure, as and when needed. Under no circumstances, should psychiatric help be discontinued for SHG members with mental health issues.

VI. Social bonding among the members is integral to their happiness and productivity. Research on the Banyan SHGs has shown that members provide a lot of social, emotional and psychological support to each other and enjoy living with each other. Research further shows that conflicts, as far as possible, are resolved within the group. In The Banyan, the organization provides food and medicines on a continuous basis to its members. But for purposes of sustainability and replication, it may not be possible for an organization to do so on a permanent basis. Regarding food, the SHG members should be encouraged to cook their own food from the time they move into their own homes.

As far as medicines are concerned, the organization could provide medicines during the initial stages of the SHG. Subsequently, when the SHG gets its second bank loan, a certain amount could be deposited with the NGO for purchase of medicines or each member may contribute towards her own medicines to the organisation. In case of deficit, however the NGO could fill the gap. This system could continue in all the bank loans. Incase the SHG plans to phase-off, this support could be entrusted to a trusted community worker, say an ANM /or an aanganwadi worker.

All these strategic decisions should however be intimated to the members at the beginning of the SHG formation itself so that at no point the members feel cheated or betrayed and prepare them selves accordingly.

V. Alternative support for psychiatric medicines could be sought by the NGO from the nearest PHC and the NGO could work towards signing a MoU with the PHC/ District Collector at an early stage so that members are assured of continuous support for medicines. A strategic decision on sustainability of NGOs needs to be made within the organization prior to formation of SHGs or expanding its portfolio.

VI. Dynamics of SHGs: SHGs of women with mental health issues tend to draw a lot of emotional and psychological support from each other and also from a few key, active and trusted members. When such members leave as they sometimes do, it leaves a void in the group as the members find it difficult to cope without them. In such cases the role of the intermediary organization, the NGO here, becomes important as they would need to re-inspire and motive the group. It would be interesting to study how the SHG re-builds itself after the exit of certain members and reshapes its future course of action.

Conclusion: Evidence from research has shown that there is a lot of support from the community for women with mental illness / women with any kind of disability. While part of it could be the strategic designing and effective implementation of the community mental heath programme of the Banyan, part of it could also be the higher levels of health index, awareness and literacy in Tamil Nadu when compared to rest of the country. This could be an interesting theme of further research.

While the above recommendations may not be exhaustive in designing the SHG model of homeless women with mental illness into a sustainable one, it needs to be just added that the concept and design of the ‘self-help group model’ itself is very strategic and empowering provided it is implemented with the commitment and responsibility it deserves to become a holistic model of social and economic empowerment. Intermediary organizations implementing the SHG programme like NGOs, micro-finance institutions (MFIs), banks etc need to be clear in their focus and agenda. Only then will the SHG model yield optimum results both for the organization as well as the clients.

Regarding SHGs of homeless women with mental health issues, the focus is clearly on social, psychological and economic well-being of women with priority on social and psychological wellness. For this it is important that the intermediary organizations need to design and customize the model according to their unique socio-cultural settings and availability of financial resources so that it is a sustained model of social wellbeing and economic independence of SHG women.

About the Author Madhu Sharan is a sociologist, having her Post Graduate and M. Phil studies from Jawaharlal Nehru University, New Delhi. She is currently completing her Doctoral research on the theme of ‘Empowerment of women in Micro-finance Programmes. She was the Executive Director of BALM from August 2007 to March 2010.

Self-help groups as an Alternate Model of Rehabilitation of Homeless Women with Mental Illness – a case study of  2 SHGs of The  Banyan, an NGO in Tamil Nadu, India

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