Mental health care system - Role of voluntary organizations

MENTAL HEALTH CARE SYSTEM·
ROLE OF VOLUNTARY ORGANIZATIONS
Thesis Submitted for the Degree of
Doctor of Philosophy
in Sociology
by
K.Asha
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DECLARA nON
I declare that this thesis entitled "Mental Health Care-Role of Voluntary
Organizations" is the result of my own work and that it has not been submitted previously
either wholly or in part, to this or any other University for any degree. Due
acknowledgements have been made wherever anything has been borrowed from any
other sources.
Date: '1 / 0 -:. ' (K.ASHA)

CERTFICATE
I hereby certify that the present thesis entitled "Mental Health Care System - Role
of Voluntary Organizations" incorporates the results of the independent research of Ms.
K.Asha, carried out under my guidance and supervision.
I also certify that it has not previously formed the basis for the award of any
Degree, Diploma or Associate Fellowship of the Osmania University or any other
University.
Date:

Acknowledgements
Firstly I am indebted to my Supervisor and guide, Prof G S Aurora who has
shown great patience in seeing this work through. These nine years of association with
him has been a very memorable one. It has been a great learning experience for me. He
has been a very inspiring force, encouraging me at every stage of my work. I am very
grateful to him for his valuable gUidance. My thanks are due to Prof G K Karanth, Head
of the Sociology Unit, ISEC, for offering valuable suggestions and comments and for
being an encouraging force to complete thIs study. I am also thankful to the staff of
Sociology Unit at ISEC and the other staff for helping me at different stages of my study.
Many of them have offered valuable suggestIOns and I am very thankful to them.
Many professionals ofNIMHANS and other InstitutIOns have been very helpful 10
. me during the study. My thanks are due to these professionals, Prof Srinivasa Murthy,
Prof G. G. Prabhu, Dr. Kalyana Sundaram, Mohan Issac, Dr. Sarada Menon, Dr.
Urmila, Dr. Suss ie, Dr. Juvva Srilatha and many more. 1 am very thankful to the staff of
the Voluntary organi::ations, who helped me a great deal offering all the information 1
needed for the study. I am very grateful to Mr. V. S. Parthasarathy for having kindly gone
through the manuscripts and offering me very valuable suggestions.
I am very grateful to Mr. Satishchandran, the then Director of ISEC, for giving
me the opportunity to work for my Ph.D. at the Institute of Social and Economic Change .
. My thanks are also due to Dr. P V Shenoi the ex. DIrector of ISFC and Dr. Govinda Rao,
the present Director of ISEC for all the help and encouragement. I thank all the ISEC
staff who have helped me during the course of my study.
1 am very grateful to Prof and Head, Department of SOCiology, Prof Narasimha
Reddy and Prof Raghavendra Rao, Osmania University, for all their encouragement and
help. 1 am also grateful to the Dean, Social Sciences for giving me suffiCient time to
complete the study.

1 am very grateful to my family members, especially my mother for her love and
affection and encouraging words that helped me to jight against many odds to complete
this work. My husband Nagaraju, has been a powerful and inspiring force throughout,
being with me during all the good and bad times to see this work through. 1 am very
much indebted to my two sons, Suhas and Vikas, jar patiently waiting to see my work
through. 1 am very grateful to my friend, S. Manasi jar encouraging me and helping me
through hard times. ThiS work could not have been possible if not for the kind ho,lpitality
rendered to me by Smt. Lalitha and her family members. She not only mothered my
children but also showed so much of kindness and affection that helped me to compete my
work. 1 am very grateful to her and her familly members, Sri Subbanna Manja, Mural!,
Sunitha and Sudha for all their help during the final stage of my work.
Lastly, 1 am very grateful to the subjects of my study the mentally ill, who have
been very kind and co-operative to me sharing their JOYs and sorrows, helping me to
understand the problem of mental illness. 1 am very grateful to them for giving me thiS
umque experience.

There is something in you that is important,
Deeper than your psychosis,
Your violence and your hatred
Above and beyond that,
There is something in you that is
Wholesome and beautiful and
Capable of doing beautiful things.

CONTENTS
Chapter No. Title 'ap
1 Introduction
2 Mental Health- A Historical Perspective 39
3 Voluntary Sector in Mental Health Care 72
4 The Three Cases 94
5 Voluntary Organisations and Patient Care 135
6 Voluntary Organisations and Patients' Families 199
7 Summary and Conclusion 235
Appendix 1
Bibliography

Chapter One
INTRODUCTION
Mental health is an integral part of total health. India is a signatory state to the Alma
Ata Declaration, which envisaged health for all by the year 2000 as the goal. Efforts to
ensure the achievements of this goal included approaches and strategies for the improvement
of all aspects of health - physical, mental and sociaL
Till recently, the importance of mental health in the national health planning was not
adequately emphasised. The scope of mental health was confined only to the treatment of
some seriously ill persons admitted to the mental hospitals. Mental health has not yet found
its appropriate place in the national and state health planning, perhaps due to a
misconception that incidence of mental illness is low in India particularly as compared to the
Western countries. According to various epidemiological surveys, the magnitude of major
psychiatric disorders in India is to the tune of 10 to 20 per thousand of population. This
constitutes at least 8 million people suffering from severe mental disorders in India. If the
figure of neurotic and psychosomatic disorders were included, the number would increase
at least three folds. About 15 to 20 per cent of all patients who seek help in general health
services do so for emotional and psychological problems.
Dr. Taylor in his report to the Bhore Committee (1946) has observed:
even if the proportion of mental patients in India be taken as 2 per 1000 of
the population, hospital accommodation should be available for at least 800,000
mental patients. On the other hand, there are only a little over 10,000 beds for such
patients ... In India, the existing number of mental hospital beds is in the ratio of one
bed to about 40,000 of the population (taking the present population of the country
as 400 millions) while, in England, the corresponding ratio is approximately one bed
to 300 of the population ...
After 54 years of independence, the number of total beds has doubled to a little over
twenty- two thousand. The number of mental hospitals has increased from 17 to 61 but the
1

ed ratio has remained the same. The mental health problem by the year 2010, it is
estimated, will emerge as the major health problem in India. According to WHO, in any
country including India I per cent of the population suffer from severe incapacitating mental
disorders and 10 per cent from mild mental disorders. If these figures are projected for India,
there would be 8 million mentally ill and ten times of that number of mildly ill persons
(WHO, 1975).
While there are millions of people suffering from various types of mental disorders,
the mental health manpower and mental health care facilities are very meagre. Total health
bed in India are less than 0.7 per 1000 population, out of which psychiatric beds constitute
only 0.033 which comes to one psychiatric bed per 32,000 population. Out of about 20,000
beds available, more than 50 per cent beds are occupied by chronic patients (GO I Report,
1990).
To overcome this paucity of manpower, there have been various attempts to improve
the mental health services in India. In 1960, in the first conference of Medical
Superintendents of Mental hospitals, a call was given for short period of training in
Psychiatry to medical auxiliaries. In 1971, another workshop on "priorities in mental health
care" called for all health workers to be provided with instruction in mental health and
mental illness suited to their level of Professional training. The most recent attempt in this
direction has been through the National Mental Health Programme (NMHP) (1982)
developed by the Director General of Health Services (DGHS), New Delhi.
The NMHP had for its aims the following:
(i) Prevention and treatment of mental and neurological disorders and their
associated disabilities.
(ii) Use of mental health technology to improve general health services.
(iii) The application of mental health principles in total national
improve the quality oflife.
development to
2

Tht;: first opportunity to develop a plan of action fo\lQwil1& th.e fonn~l~ti09

another, at least 2-3 per cent of the population are suffering from minor forms of emotional
disorders which are responsible for an individual giving much less than his best to the
society. In fact a total count of man-days lost to the nation attributable to mental disorders
would be staggering (WHO, 1975).
The physical and mental health of an individual is inter-related and no health
programme can be considered complete without adequate provision for the treatment of
mental ill-health and for the promotion of positive mental health.
Positive mental health is characterised by discriminative self-restraint associated with
consideration for others. A man in such positive health uses effectively his intelligence and
talents to obtain the maximum satisfaction from life with minimum discomfort to others.
Such a person will not allow himself to be overwhelmed by the stresses and strains
inseparable from ordinary existence. He not only profits from experience but under
favourable circumstance, can transcend such experience (Davis, 1938 cited in Kamo and
Schwartz, 1974).
Davis (1938) observes that the ultimate in mental hygiene means mental poise, calm
judgment and an understanding of leadership and fellowship, in other words, cooperation
with an attitude that tempers justice with mercy and humility (Kamo and Schwartz, 1974).
Beirer et.al .. point out the importance of good mental health and the role it plays
throughout man's life. He observes that the most important aspects of mental health is the
state of the ego, what has been assessed as the quality of the ego structure and the stage of
its development, or what is called the maturity of the ego. Personalities develop, even before
birth, but certainly during life and they continue to develop throughout life. To assess a
person's personality, one of the criteria is the stage of his development (Beirer et.al., 1970)
ofa person:
According to Beirer et .. al., there are three main areas to assess the state of the ego
4

(1) Reaction to stress: The capacity of the person to wi thstand frustration and to
tolerate anxiety and depression. What is being assessed is the degree of control of
the ego in maintaining its equilibrium in the face of different pressures.
(2) Problem solving: The capacIty of the ego to solve the problems that seem to
threaten the equilibrium state of mind.
(3) Adjustment to reality: To assess how far the person has achieved a happy oillarice---'
between, on the one hand gratification of his needs and instincts and impulses and
on the other hand, sacrifice of the gratification of these needs to the demands of
reality.(Beirer el.al, 1970).
A healthy person has a sound body and leads a happy and contented life, has the
ability to face difficulties, losses and frustrations. He is capable of living in harmony with
others, not only is he happy but is able to do his best to keep others happy. He has certain
moral and spiritual values and sees that others are not put into trouble because of him. Such
a person who is physically, mentally, socially and spiritually well can be considered to be
healthy (NTMHANS, 1985) Thus, mental health plays a very vital role in the lives of all
human beings and good mental health leads towards the progress of the society.
Statement of the problem
Like the body, the 'mind' too can become ill. The mentally ill person's sense of wellbeing
and equihbrium is disturbed. The various mental functions like thinking, emotions,
memory, intelligence, decision-making, etc., get disturbed. Speech and behaviour become
abnormal. The ability to work satisfactorily IS impaired.
There are certain disorders of thought processes and emotional states that seem to
occur in all societles that lead to problematic behaviours which are disruptive of normal
social relationships that usually cause torment to the individual afflicted by the disorder and
that tend to fluctuate in intensity depending on the 'individual's physical condition and
features in his life history.
5

Whether such conditions are regarded as diseases or not, it is relevant to ask how
cultural themes, social roles or sequences oflife experience may influence the incidence of
various forms of disorder, the ages at which such forms occur most frequently, the course
of disorder and its consequences for the social participation and subsequent functioning of
the individual. Thus, it is relevant to study the processes by means of which the problematic
behaviour problems can be defined and dealt with or treated within a given culture and social
milieu.
Mental disorders occur in all societies. Social conception of mental disorder varies
greatly. The examination of societal responses to mental disorder affords an opportunity for
the study of a number of sociological problems.
They are, -
(I) the nature of behaviour that leads to a person to be seen as 'mentally ill;
(2) the consequence of calling a person 'mentally ill' or of confining persons so
diagnosed in mental hospitals;
(3) the social identity of the individual afflicted; and
(4) the characteristics of the institution that influences the behaviour of inmates.
Whether or not the socio-cultural factors are implicated in mental disorder, being a
mental patient has important consequences for the life course and social roles of patient and
his family. Care for the mentally ill is very crucial and it involves social and economic
resources. Allover the world different strategies have been adapted to tackle the problem
of care for the mentally ill. Attitudes of the people have also been changing since the days
when mentally ill were tortured. Care for the mentally ill is very important but yet due to
financial constraints especially in a developing country like India, facilities turn out to be
meagre and alternative institutions of care have to be evolved to tackle the problem, In this
study, an attempt has been made to assess the facilities available in India and highlight the
role played by voluntary organizations.
6

How do voluntary organizations (VOs) function, what is their structure and how do
they mobilise resources of the societal institutions to help the mentally ill IS the central theme
of the study. The study attempts to understand the various societal perceptions WIth regard
to the definition of mental illness, identification of those afflicted by mental Illness,
definition of symptoms of mental illness, society's response to those afflIcted by Illness and
those working towards their betterment. The study tnes to understand the voluntary
organizations as one of the means by which society seeks to solve the problems of those
afflicted by mental illness and the families of the mentally ill.
Objectives of the study
I. To place the problem of mental health in lndia in a historical perspective.
2. To describe the role played by the voluntary organizations in the identification,
treatment, rehabilitation and prevention of the mentally ill.
3. To study the structure and functions of the voluntary organizations as related
to the care and cure of mentally disturbed patients.
4. To examine the linkage of voluntary organizations with the Governmental
organization and with each other.
5. To understand the role played by the families towards the care of the mentally
ill.
Operational definition of the concepts used
Mental Health: This refers to the integrated state of mind and body possessing
characteristics that help a person to adjust satisfactorily with hislher personal and social life.
Voluntary Organization(VO): This refers to those organizations working towards
social welfare, which are non-government, non-profit making in character and not fully
funded whether directly or indirectly only by the government.
7

Theoretical framework
The study has for its basis the theories of Parsons on structural-functionalism, his
theory on open systems and his contribution to the sociological approach to the society.
Parsons's structural-functionalism
According to Parsons, "A social system consists of a plurality of individual actors
interacting with each other in- a situation which has at least a physioalorenvironmental
impact, actors who are motivated in terms of a tendency to the 'optimisation of gratification'
and whose relation to their situations, including each other is defined and mediated in terms
of a system of culturally structured and shared symbols" (Parsons, 1951).
Parsons believes that there are four functional imperatives that are necessary for or
characteristic of all systems-
(A)-Adaptation, (G)-Goal attainment, (I)-Integration, (L)-Latency or Pattern Maintenance
(AGIL). In order to survive, the system must perform these four functions.
1. Adaptation: A system must cope with external situational exigencies. It must adapt to its
environment and adapt to its needs.
2. Goal attainment: A system must define and achieve its primary goals.
3. Integration: A system must regulate the inter-relationships of its component parts. It must
also manage the relationship among other three functional imperatives (A,G,L).
4. Latency (Pattern Maintenance): A system must furnish, maintain and renew both the
motivations of individuals and cultural patterns that create and sustain motivation.
With the above theoretical assumptions in mind, this study looks at the role of
voluntary organizations treating them as social systems. The role of these social systems will
be assessed by assessing the functions they are expected to perform, viz., Adaptation, Goal
attainment, Integration and Pattern maintenance (Parsons' A,G,I,L). The research questions
that can be posed are: how do these organizations adapt themselves to the external
8

environment? What are the steps taken by these voluntary organizations to achieve their
goals? How do these organizations integrate the staff, duties and other sub-organizations in
their course of achieving their goals? How do these organizations maintain a particular
pattern in order to sustain motivations of individuals and also to maintain a cultural pattern?
Apartfromtheabove, the organizations-will atso be analysed from the view point of .. -............ ..
Parsons assumptions of order, inter-dependence of parts, impact on the other sub-systems,
and self-maintenance of a system.
Parsons's Open-System Theory
Parsons's open-system theory is based on the entropy assumption and the emphasis
on the necessary dependence of any organization upon its environment According to him,
L There is a close relationship between a structure and its surrounding environment and
without continued inputs the structure would soon run down. One critical basis for
identifying a social system is through its relationship with energic sources for its
maintenance. Human effort and motivation are the major maintenance source for
almost all social structures.
2. Another major relationship is the processing of production inputs to yield some outcome
to be utilised by some outside group or system.
INPUT • THROUGH-PUT • OUT -PUT
3. The open-system approach permits the integration of macro-approach of the sociologists
and micro-approach of the Psychologists to the study of social phenomena.
Parsons offers certain criteria for understanding organizations, which are as follows.
I. An organization is a social device for efficiently accomplishing through group means
some stated purpose; it is the equivalent of the blue-print created for some practical
objective.
2. Rather than starting with concepts which call for identifying the purposes of the designers
and then correcting for them when they do not seem to be fulfilled, the theoretical
concepts should begin with the input, output and functioning of the organization as a
system and not with the rational purposes of its leaders.
9

3. The theoretical model for the understanding of an organization is that of an energic inputoutput
system in which the energic return from the output re-activates the system. Social
organizations are flagrantly open systems in that the input of energies and the conversion
of output into further energic input consist of transactions between the organization and
the environment
4. All social systems, including organizations consist of the patterned activities of a number
of individuals. These patterned activities are complimentary or inter-dependent with into
some common output or outcome; they are repeated, relatively enduring and bounded in
space and time. The stability or recurrence of activities can be examined in relation to the
energic input into the system and the resulting product or energic output. To maintain
these patterned activities requires renewal ofthe inflow of energy. This is guaranteed in
social systems by the energic return from the product of outcome. Thus the outcome of
the cycle of activities furnishes new energy for the initiation of a renewed cycle.
Two basic criteria for identifYing social systems and determining their functions are
1. tracing the pattern of energy exchange of activity of people as it results in some output;
and
2. ascertaining how the output is translated into energy, which re-activates the pattern.
Therefore, we shall refer to organizational functions or objectives not as the conscious
purposes of group leaders or group members but as the outcomes, which are energic
source for the maintenance of the same type of outputs.
Reflections
The theoretical assumptions made for the analysis are as follows: There is a close
relationship between any social system (in the present case, voluntary organizations) and its
surrounding environment. It depends on continued inputs and it requires energic resources
for its maintenance. Human effort and motivation are the major maintenance source. The
system yields certain outcome to be utilised by another system.
10

Fig 1.1 Social System And The External Environment
Vos working for the
mental health of the
patients
INPUT
(TIIROUGH PUT)
EXTERNAL ENVIRONMENT
Organization is a social device for efficiently accomplishing through group means
some stated purpose. The energic return from the output activates the system. The input of
energies and the conversion of output into further energic input consists of transactions
between organization and the environment in the form of patterned activities, interdependent
or complimentary involving a cycle of events. To maintain the patterned activity,
the system requires renewed energy which is resulted from the energic return of the product
of outcome. To survive, open systems must move to arrest the entropic process; they must
acquire negative entropy.
The figure 1.2. given below briefly describes, the input, through-put and output of
the voluntary organizations working in the area of mental health.
11

Fig 1.2. Voluntary Organizations as Open Systems
EXTERNAL ENVIRONMENT
INPUT
1. State mental health care
facilities
2. State legislation for
the mentally ill
3. Societal attitudes toward
mental illness
4. Cultural practices
L
A
I. Treated clients
2. Trained family members
3. Educated families
4. Educated masses
5. Self-help groups
6. Rehabilitated clients
7. Family networks
8. Linkage of different Organizations
VOLUNTARY
ORGANIZATIONS
1. Funding
2. Human effort
3. Altruistic motives
4. Empathy towards the mentally ill
5. Infra-structure
6. Efficient staff
7. Good Team Work
I
G
I. Mass education on mental illness
2. Care for the mentally ill
3. Training the mentally ill in
social and vocational skills
4. Training the family members of
the mentally ill in coping skills
5. Therapies for the mentally ill
6. Formation of self-help groups
OUTPUT
THROUGH-PUT
Parsons' Sociological Approacb to tbeTbeory of Organizations
According to Parsons, an organization is a system which, as the attainment of its
goal, "produces" an identifiable something which can be utilised in some way by another
system; that is, the output of the organization is for some other system, an input. There must
be a set of consequences of the processes, which go on within the organization which makes
difference to the functioning of some other subsystem of the society, that is. without this the
receiving system suffers a "deprivation" (cited in Etzioni, 1961).
12

In analysing an organization, firstly, it is treated as a system, which is charecterised,
by all the properties, which are essential to any social system. Secondly, it is treated as a
functionally differentiated subsystem of a larger social system. Thirdly, it will be the other
subsystem of the larger one, which will constitute the situation or environment in which the
organization operates. Further, it has to be analysed as the special type of social system
organised about the primacy of interest in the attainment of a particular type of system goal.
Certain of its special features will derive from goal primacy, in general and others, from the
goal primacy of the particular type of goal. The characteristics of the organization will be
defined by the kind of situation in which it has to operate, which will consist of the relations
obtaining between it and the other specialised subsystems of the larger system of which it
is a part. The latter for most purposes is assumed to be a society.
According to Parsons, the structure of the organization can be described and analysed
from two points of view. First is the cultural-institutional point of view, which uses the
values ofthe system and their institutionalisation in different functional contexts as its point
of departure; the second is the 'group' or 'role' point of view which takes sub-organizations
and the roles of individuals participating in the functioning of the organization as its point
of departure.
According to Parsons, a minimal description ofan organization will have to include
1. the value system-which implies basic acceptance of the more generalised values of the
super-ordinate system (unless it is a deviant organization not integerated. and 2. at the
requisite level of generality the most essential feature of the value system of an organization
is the evaluative legitimisation of its place or 'role' in the super-ordinate system.
organization.
The analysis of the organization should look into the following aspects of the
I. Procurement of the resources necessary to carry out its functions.
2. Institutional procedures which these resources are brought to bear in the concrete
processes of goal attainment.
13

3. Institutional patterns defining and regulating the limits of commitments to the
organization.
Apart from the above, the analysis of organization should also include mechanisms
of implementation, which involves two sets of relations. First, is the set of relations with the
external situation centering around the problem of 'disposal' of the 'product of the
organization's activities. Second is the process concerned With the internal mechanisms of
the mobilisation ofresources for the implementation of the goaL Both of these involve the
following functions:
1. Policy decisions which are a set of decisions to take steps to attain the goaL
2. Allocative decisions which involves allocations of responsibilities among personnel,
i.e., sub organizations and individuals, and the allocation of resources, i.e., manpower
and monetary and physical facilities in accord with these responsibilities.
3. Co-ordination decisions which maintains the integeration of the organization through
facilitating co-operation and dealing with the motivational problems which arise within
the organization in relations to the maintenance of co-operation. According to Bernard
(1938), the first two decisions determine the effectiveness of the organization and the
third determines the efficiency of the organization (cited in Etzioni, 1961).
Selection of the sa m pie
A preliminary survey of voluntary organizations working in the area of mental health
with special reference to promotive curative and preventive services found that about 19
organizations were working in the area of mental health. For the purpose of the study, it was
decided to select three organizations for a complete case study. The selection of the three
organizations depended on: 1) service rendered by the organization; 2) location of the
organization; 3) size of the organization; and 4) age of the organization.
A preliminary survey was made to collect information on all these organizations and
it was found that four organizations were doing pioneering work in this field in Bangalore,
Delhi and Madras. Due to time and monetary constraints, the locations were restricted to
14

only Bangalore and Madras. Out of the 19 organizations originally considered, some had
started recently and they were yet to make good contributions, some were only crisis intervention
centres which would not fulfil all the needs of the study, some were for the families
of the mentally disturbed and some others were working exclusively for drug and alcohol
addicts. Therefore, it was decided to choose the organizations, which rendered services to
all the categories of mentally ill. Services provided by the organizations ranged from
identification, treatment, day care, custodial care, rehabilitation and education. It is relevant
to pit out that there has been a tremendous growth in the voluntary sector in recent years and
the number of organizations working in the area of mental health care has more than
doubled. At present, the total number of voluntary organizations working on mental health
care is around thirty eight. This does not include those working on mental retardation.
The organizations that were chosen for the case studies were
1) Mental Research Foundation, Madras (MRF).
2) Manasa Rehabilitation Centre, Bangalore (MRC).
3) Royal Medical Society, Bangalore (RMS).
Table 1.1. Organizations Selected for Case study
Name of Year of Coverage Benefi- Funds
Vol. Org Registration Clarles sources Staff
MRF 1983 Urban Mentally ill Local Prof: 14
and rural National Admn: 6
International Suppl :12
Vol: 10
MRC 1972 Urban Mentally ill Local Prof: 10
Admn: 4
Suppl:1O
Vol: 15
RMS 1980 Urban Mentally ill Local Prof: 4
National Admn: 8
International Suppl: 5
Vol: 10
15

All these three organizations have rendered more than a decade of service. This
study would also give a peripheral view of all other voluntary organizations working in this
field apart from those selected for the case study.
Methodology
Case study method has been employed in this study to understand the role of the
voluntary mganizations. With the help of case studies, an attempt has been made to describe
the efforts made by the voluntary organizations towards the care for the mentally ilL
At the initial stage, the key persons of the voluntary organizations were contacted to
discuss the objectives of the study in order to get their help and cooperation. The
organization kindly accepted our request to include them for the study and also suggested
that the researcher be a part of them as a volunteer to become familiar with their activities.
An interview guide was prepared to conduct informal interviews with the staff
members, family members and the clients of the organization. Apart from them, the funding
agencies, honorary members, committee members and the volunteers were also interviewed.
In-depth interviews were made with the clients of the organizations to elicit their opinions
on the voluntary organization and also to understand their problem of mental illness. The
method of participant observation was made use of whenever necessary without sacrificing
the objective to the extent possible.
The questions posed to different respondents can be classified in the following
manner.
I) Questions posed to the staff of the organizations.
The information that was expected to be obtained from these interviews were those
about the personal information regarding age, sex, educational status, marital status, the
nature of work of the personnel interviewed, his/her responsibilities in the organizations,
16

0
their experiences with the clients and their families, their personal feelings about working
in a voluntary organization, their attitudes on stigma on mental illness, opinions about the
voluntary organization that he/she is working in, merits and demerits of the organization,
attitudes on staff turnover in the organization, attitudes on voluntary efforts in the field of
mental health Cate andllther details. "- - n
2) Questions posed to the administrative staff to get the following details on funding,
expenditure, resource allocation and expenditure prioritisation were:
a) the profile of the staff members of the organization;
b) the funds received by the organization;
c) allocation of resources;
d) plan outlay;
e) details about the patients treated over a period of 10 years; and
f) Expenditure details on the followingresearch,
infra-structure, medicines, vocational training, payments to staff,
books, transport, maintenance charges, education/awareness material.
3) Questions posed to the clinical staff were
a) selection of the patients;
b) follow-up;
c) allotment to the personnel;
d) duration and intensity of treatment;
e) therapy offered;
f) rehabilitation services: and
g) custodial care
4) Questions posed to the public education officer were the following:
a) pamphlets to educate the masses;
b) audio-video cassettes!;
c) public meetings;
d) camps;
e) rural education programs;
f) target group for education; and
g) Success and failure of various programs conducted by the organization
Apart from those stated above the other information on the following were also
collected.
1) origin of the organization;
2) growth of the organization;
3) objectives ofthe organization;
17

4) persons responsible for starting the organization;
5) different centres of the organization if any;
6) details about linkage with other organizations;
7) ilnfrastructure facilities;
8) fees collected if any from the clients for service offered; and
9) conditions under which funding agencies granted funds.
Informal interviews were conducted with the family members to assess their attitudes
on the services rendered by the organizations.
Review of literature
Research in this field could be classified according to the major focus of the study
VIZ.,
1. Studies on the general conception of mental illness.
2. Studies on the role offamilies.
3. Studies on the institutions of mental health care and the trends.
4. Studies on economic resources and mental health.
5. Studies on social factors and mental illness.
6. Studies on the profiles of the mentally ill.
Public conception of mental illness plays an important role in identifying mentally
ill persons. It also influences the perception of the patient about his illness. Societal
conception by itself has been related to the cause of mental illness [Scheff (1966), Neki
(1966), Gove (1970), Dube (1978), G.G. Prabhu et.al., (1984)].
The role ofthe family assumes importance in maintaining the mental health of the
family members. Healthy inter-personal relationships, cohesion and integrity among family
members and good social network contribute to a healthy and sound mind of the family
members. Further, it has been found that a good perception of the problems of the mentally
amicted member by other members help in the treatment of the mentally ill persons. Thus,
family therapy has been advocated by many researchers such as Freeman and Simmons
(1958), Kanti Prakash et.al., (1973), Caplan (1974), Somen (1985), Seamen, et.al., (\985),
Cohen (1988), Barget (\989), and IlIango (1992).
18

Research findings on the cultural beliefs and practices on the cause and cure of
mental health has led to some re-thinking on fOIlIlulating mental health care. Culture-specific
health care, a active involvement of the community in health care programmes have been
found to yield good results [Brajsa (1985), Vijayalakshmi and Ramana (1987), Narayanan
(1990), Kyung (1990), Reyes (1990), Nagasami (1990)]: . .... .~..~ .
There seems to exist a relationship between economy and mental health. Social class
IS found to have an inverse relationship with mental hospitalisation. Perception of
psychological problems differ in different social classes. The lower class groups seem to
have more tolerance towards deviance. [Hardt and Dherwin (1959), Hollingshead and
Redlick (1958), Freeman (1961), Dohrenwend and Chi-Shong (1967)].
Studies on the socio-economic background and bio-social characteristics of mentally
-ill reveal that broken homes, step relation, child neglect situations, economic and social
stress, heredity, unemployment, marital status and living environment have all played
different parts in affecting the mental health of the ill [Prakash et.al (1973), Godbole (1974),
Nandi et.al., (1975)].
Lastly, studies have been conducted on the institutions of mental health care
questioning the medical model of mental disorder. They have critically examined the
existing concepts of mental disorder and institutional structures for dealing with mental
disorder and have recommended a change in handling mental disorder (Goffman, 1961).
Further studies focussing on the importance of the active participation of the
community, voluntary agencies and community mental health centres have been carried out
in other parts of the world [(Robins 1982, Brajsa 1985, Eisenberg 1980)]. This area is yet to
be explored in the Indian context. The following section deals with detailed review of the
various studies conducted in the area of mental health.
19

Studies on the public conception of mental Health
These studies may be grouped under two categories, viz., the western and the eastern.
First, we take the mach larger body of studies by western scholars. In the west, public
conception regarding mental illness plays a major role in the definition of symptoms of
mental illness and treatment. Whitt and Meile describe three processes in the defmition of .
symptoms of mental illness, viz., alignment,-in which explanations are formulated,
snowballing,-in which symptoms build on one another until they can no longer be ignored
and magnification, in which there is a tendency for the perceived disruptiveness of symptoms
to increase with the decreasing social distance. In the Blackfoot restudy conducted by Whitt
and Meile the respondents were asked to identify if something was wrong with a group of
mentally ill persons and if so whether they perceived them as mentally ill. By aligning
actions of the persons, respondents were asked if their behaviour was problematic if they
were mentally ill. The results indicated that the behaviour described was not always
regarded as problematic. For instance, the respondents considered nothing wrong with the
behaviour of the anxiety neurotic and the compulsive phobic. However, most of the
Paranoid Schizophrenic and Simple Schizophrenic were considered mentally ill.
Another process identified was that of the cumulation of symptoms, namely, the
process of snowballing, the effect of different problematic behaviour. The other process
referred to as magnification refers to the tendency to exaggerate problematic qualities, the
likelihood that the symptoms of mental illness would be perceived as a problem as and when
there is an increase in the social distance from the afflicted person. Whitt and Meile
concluded that the ways in which problematic behaviours are understood are not necessarily
derived from shared cultural definition of mental illness but the manner in which people
consider behaviour as problematic and the situation under which the symptoms are
problematic (Whitt and Meile, 1985).
Louisville's study on the attitudes of western people regarding mental illness and
treatment brought out very siETIificant findings. Firstly, it was found that the public had
come a long way in giving up old beliefs and superstitions about mental illness and in
20

adopting more modem and scientific conception. Secondly there was still a gross failure to
recognise severe mental illness symptoms. Thirdly there was a loss of faith in the repressive
and punitive technique especially in dealing with juveniles. Fourthly there was no strong
opposition to the consultation of Psychiatrist and he was regarded as the logical person to
handle clearly identifiable-cases of mental disorders although there was a stigma. Finally
there seemed to be an opposition from the lawyers against Psychiatry and the modern
methods of treatment of juvenile delinquency (Woodwards, 1967).
Among the educated there seemed to be more consistent, stable and crystallised
information and lack of information existed only in some areas and gross misinformation did
not seem to exist (Nunnally, 1961, Rahmathullah and Satyavathy, 1977).
Attitudes among educated laymen and mental health professionals showed that the
mental health information held by educated laymen were not well crystallised yet there
seemed to be no marked difference from the experts as both had neutral rather than firm
opinions. The less educated as well as older respondents seemed to be misinformed
(Basumallik and Bhattacharya, 1983).
Another study reported similar findings. The educated lay public showed no sign of
misinformation but some lack of information on certain areas. The older people above the
age of fifty years looked upon mental illness as a hopeless condition and preferred to
maintain greater social distance from the mentally ilL Women showed better awareness of
mental illness than men. Higher education and contact with the mentally ill did not seem to
mfluence the respondents' orientation towards mental illness. The educated lay persons
viewed the mentally ill as aggressive, violent and dangerous. Optimism about the outcome
of treatment was not high. There was lack of awareness about available facilities to treat the
mentally ilL Pervasive defeatism and a tendency to reject the mentally ill existed in the
sample studied (Prabhu el.ai., 1984).
To some extent, the English educated and westernised segment of the Indian people
would display considerable similarity with the western "public". Dube's study deals with
21

the Indian respondents. It points out that a great deal of misconception, superstition and
ignorance exist in respect of mental disease. Stigma is often attached and mental illness is
viewed as a visitation of evil spirits of a Goddess of curse. There is exaggerated belief in
mystic influences, excessive faith in the powers of saints, priests and medicants. Public opt
to go to sorcerers,-faith'heatcrs, -priests and-to places of worship for cure. -Many return
disillusioned and resort to mental hospitals (Dube, 1978).
In the Northeastern parts of India, all mental illnesses are believed to be the same.
The cause is attributed to shock, sexual starvation, heat and possession. Mentally ill are
viewed as people with no capacity for understanding. The public are highly pessimistic
towards cure and treatment of the mentally ill (Verma, 1975).
Malhotra and Wig (1975) investigated the ways in which the public managed an
individual with a deviant behaviour and concluded that psychological possession, social
manipulation, medical intervention, dietary regulation and mental health consultation,
mystical and religious modes along with the tendency of not seeking any type of intervention
constituted ways of handling deviant behaviour and this was largely influenced by the socioeconomic
strata of the individual with the deviant behaviour and those managing them.
Murthy used vignettes to study the attitudes towards mental disorders in a village in
Punjab and concluded that more serious forms of psychiatric disorders (Psychoses) were
correctly recognised and were considered as serious enough and to be taken for medical
intervention. The respondents showed lack of sensitivity to recognise the problems of the
alcoholic addict and the child with behavioural disorder. They seemed to be aware of
services available at mental hospital but lacked information about psychiatric facility in a
general hospital setting (Murthy et.a/., 1978).
A study conducted, on the perception of mental disorders and reaction to them, the
help seeking behaviour and the perception of the role of traditional medicine and healers in
caring for the mentally ill, showed that they preferred modem health services rather than
traditional healers in the case of mental disorders and the three conditions identified by
22

them were epilepsy, acute psychoses and mental retardation. The study suggested that there
were strikingly pessimistic comrnWlity attitudes towards the social consequences of mental
disorders (Wig et. aI., 1981).
A study conducted on an Indian professional group, on the conceptualisation of a
mentally ill person, revealed that there was a high degree of simplification andformation of
rigid notions about the mentally disturbed person. He was either a highly intelligent person
or ignorant. The neurotic person was either a yOWlg woman or an ignorant person who was
Wlloved and lonesome in childhood. Childhood experience and security were stressed as
important aspects to maintain good mental health. Awareness regarding centres oftreatrnent
existed and the mental hospital represented a place of hope for them. The respondent group
did not have negative attitudes towards mental illness and also showed willingness to interact
with the mentally ill. Losing interest in the surroWlding and losing self-control were
attributed as the most common symptoms of mental illness. The respondent group expressed
optimism regarding the outcome if the patient was treated by a professional for a long time
(Satyavathi et. aI.,1971)
The study conducted on the public conception of mental health foresaw two possible
results that the public was either misinformed in the sense that the average man holds
numerous misconceptions about mental illness or the public was uninformed, i.e., the
average man has little information, correct or incorrect, about many of the problems and it
was inconceivable for the researcher that the average man could be well-informed. The
results clearly showed that the average man was not grossly misinformed. They fOWld that
because of the anxiety associated with the mental health topics and partially because of the
lack of semantic referents for his terms, the average man did not systematically learn about
mental health phenomena from daily experience (Scheff, 1974).
Some of the causes of mental illness mentioned were emotional factors, God's
punishment for sin, excessive thinking and organic factors. Very few attributed mental
illness to poverty, heredity and evil spirits and many felt that there was a relationship
between moon and mental illness (Verghese and Baif, 1974).
23

The study on attitudes of the people towards the mentally ill showed that a stigma
clearly existed. There was a strong negative halo associated with the mentally ill. They were
perceived as 'bad', mostly unpredictable and dangerous, dirty and intelligent, insincere,
worthless. Public interest regarding mental health topics seemed to be more towards
knowing the solution for the problem and not those that raised anxiety (Scheff; 1974).
Mental health information did not seem to be influenced by sex nor contact with a
mentally ill person in the family. There seemed to be limited information on mental health
issues among the public which was not crystallised and to a large extent they were
uninformed and not misinformed (Satyavathi and Dwarke,1972).
Studies on economic resources and mental illness
Attitudes of the Indian people regarding mental illness seemed to vary with education
and income. The study by Verghese and Beig revealed that most of their respondents of all
classes had experience with mental patients, and a few were also aware of varying types of
mental disorders. Causes for mental illness seemed to be understood in varying ways.
Majority showed sympathy towards mental patients and accepted modem methods of
treatment available in the hospital. Yet some people preferred to seek recourse to witchcraft,
religious centres and ayurvedic systems. Some believed marriage would bring improvement
in the condition of the mentally ill. Optimism regarding treatment if given early was
expressed by some people and a few were pessimistic they believed that mental illness was
incurable. There seemed to be a positive trend regarding mental illness with higher
education and income. But most were against marital alliance with a family which had a
positive history of mental illness (Verghese and Beig, 1974).
24

Studies touching upon 'stigma'
An investigation on the type of infonnation that reduced stigmatisation of
Schizophrenia found that those who had no prior contact with a mentally ill person perceived
mentally ill as dangerous and preferred to be away. With regard to stigma, a knowledge of
the symptoms associated with the acute phase of Schizophrenia created more stigma than the
label of Schizophrenia alone. On the other hand, knowledge about the condition of after care
reduced negative judgements. Thus, the findings suggested that stigmatisation might be
reduced by promoting direct contact between the public and individuals afflicted by mental
illness (Penn el. ai., 1994).
One of the Western studies on the relationship between social status and attitudes
towards psychological diseases revealed that the Psychiatrist's point of view coincided Vvith
the view of high status groups. Tolerance of deviance seemed to be more among the low
status groups. As for the seriousness about mental illness, paranoid schizophrenia was
considered to be the most dangerous in congruence with the Psychiatrist's point of view. The
study concluded that there had been a growing acceptance of mental health orientation
towards problems of deviant behaviour especially in the high status groups. Second, that
there was an apparently greater tolerance of deviance in low status groups. The lower status
groups were pre-disposed to greater tolerance ofthe kinds of deviance that both they and the
higher status defined as serious mental illness. The appearance of greater tolerance of
deviant behaviour in low status groups was an artefact of viewing their attitudes within a
high frame of reference. When both lower and upper status groups defined a pattern of
behaviour as seriously deviant, lower status groups were less tolerant. The relatively tolerant
policy of upper status groups appears to be a consequence of their generally more liberal
orientation rather than that of comprehension of the nature of psychopathology in psychiatric
tenns (Dohrenwend and Sung, 1987).
Another study on social resources and economic resources and their effect on mental
hospitalisation suggests that lower the economic strata ofthe mentally ill member,-greater
the negative attitude towards psychiatric treatment and delay in seeking psychiatric care.
25

When they did get treatment, the disorder was quite severe. Similarly, the unmarncd illd
not revive treatment and the married received prompt treatment and care. Thus It was found
that economic resources and social resources in terms of being married gave the individual
afflicted by mental illness more scope for treatment and care (Gove and Howell, 1974)
Studies on tbe role of families
In the West, a high level of performance was seen among those with instrumental
role that too in the conjugal families; it was found that the tolerance of deviance by
"significant others" in the families determined the success rate of the recovery and
rehabilitation of the patients. Familial network in which the patient resided and his status
within the network played a very important role and it determined the recovery rate of the
patient. The study warns the medical practitioners regarding the release ofthe patient to a
tolerant commwlity setting, where the patient had no instrumental role, thus giving him less
chances of recovery leading to regression rather than better functioning. There seems to be
some association between the structure of the family and the performance levels of the
patients. It was found that the low level of performance was present in parental families and
these patients played a role ofa child in the family and their non-instrumental performance
was well accepted (Freeman and Simmons, 1958).
Family plays a very important role in every aspect of life. This is true of western
studies and even more so of the Indian ones. Family has an obvious significance at the time
of identification to rehabilitation stages. A case study of a patient experiencing the presence
of a mentally ill member revealed a very pathetic picture of the trauma undergone by the
family. The family experienced a lot of difficulty in finding a residential care centre to take
care of the ward and to help him lead a normal life. Another major difficulty faced by the
family was during the violent phase of the member when they were forced to take the help
of the police to control their own childlbrother, any other family member afflicted by illness.
The most humiliating act was that the police expected the family to press charges against
the member in order to take action. Very meek parents who could not cope up with this
situation were trapped for long until they found a good place of stay for the ward. In the
26

hospitals once again, lhey were left in suspense as the patients were kept behind locked
doors.
Parents sometimes felt a sense of guilt that the illness was caused by them. The
presence of the ill member at home drove away many relatives and friends because of the
strong stigma attached. The biggest worry of the parents was the future of the ill member
and who would care for him after their death (Mittleman, 1985).
Another case study focussed on a family that successfully played a social role in
rehabilitating a schizophrenic member to a normal living. The family under study underwent
all the stress and burden in a brave way and brought the afflicted individual to nonnalliving.
The family members took care of all the needs of their member and often gave feedback and
guidance to the member. The family gave the member a sense of identity and also mastered
effective management of emotions and saw to it that the member maintained emotional
stability. The family members gave first priority to love and affection of the family members
and indicated status in society to be their last priority. Thus, the family with its close-knit
character helped in a great way to rehabilitate the afflicted member. The author emphasises
the potential that exists within a family unit that needed to be relied upon to restore and
strengthen the individual. The study also points out the need for creating the family
boundaries (Balachandran, 1985).
The study on coping structures of families with a mentally ill member was studied
after their first visit to the Psychiatrists to find out the different sources of help the families
sought before they met the psychiatrist. A majority of them perceived the illness as
possession by evil spirits. Some perceived as some other illness.
Families usually resorted to traditional forms of treatments, viz., Talisman, Raksha
Reku, Bhutha Vaidyam. The study revealed the fact that the families experienced difficulty
III the management of the illness resulting in the delay in the detection of the illness. This
further led to chronicity due to lack of medical attention and a delay in recovery and
rehabilitation of the patient. The study also showed that the chances ofthe patients being
27

successfully treated and rchabihtated were minimal. The people suffered from lack of clarity
in reaching help source and remedy. This prompts for proper mental health planning to
facilitate families in early detection and treatment (Vijayalakashmi and Ramanna, 1987).
A study of conditions in India suggested that knowledge levels: expectations and
perception of parents towards the child with mental handicap were important variables.
There were generally three types of families with varying levels of knowledge, families with
adequate disposition, those with inadequate disposition and those with near adequate
disposition. The famihes of the first type needed courage, support and upgradation of skills
and involvement at higher level of policy making and the second type required intensive
counselling to remove negative attitude and therapy for emotional adjustment, intensive
training for knowledge building, and the third type required strengthening of knowledge and
more guidance. With the intervention of a social worker, the knowledge, attitude and
perception of the famihes cou~d be changed towards a positive direction resulting in their
better participation in rehabilitation of the afflicted member (Narayanan, 1990).
The Indian famihes have a greal potential of care-giving for the afflicted member.
A study by Dalal notes that warm relationship in the family helped in deahng with a disease
whereas vulnerable families instead of offering support needed support for themselves in
crisis situation. He suggests the need to identify families and involve professionals to build
realistic expectations about the disease and its ramifications. For any meaningful
intervention, it is important to identify families, which have the resilience and resources to
provide support to sick members and the families, which are vulnerable and need support.
The mode of intervention needs to be different for different families. An early identification
of vulnerable families would help in planning treatment procedures, secondary prevention
and rehabilitation of people with chronic diseases. The study suggests that family
intervention along with the cultural disposition in mind would go a long way in developing
coping skills of the families (Dalal, 1985).
In India, family plays a crucial role in health care and medical intervention. Gore
(1968) and Sinha (1996) note that India has a long history of stable family life and structure
28

and has survived the test of times. Even during social upheavals the family structure and a
sense of collective responsibility have been the sustaining influences. As an institution, the
Indian family has shown remarkable adaptability in meeting the demands of a changing
world. Many studies have found that Indian traditional family system has a crucial role by
being the primary care giver.
Sinha (1996) argues that many of the traditional features of the Indian family helped
it to support the deviant individuals. He argues that though the joint family system is
weakened in most of the big cities, it had not yet acquired the typical structure of a nuclear
family. Gupta (1978) observed that a new nuclear family did not exist as a separate entity
but existed as a sector of the continuous extended family arrangement. According to Gore
(1968), structurally, the extended family was tending to become nuclear, but functionally it
IS maintaining the joint family structure. Many researches have found that joint families
provided a larger support base, which acted as a buffer against the stress of disease or
disability (Kakar, 1982, Sethi and Sharma, 1982). Another study pointed out that due to lack
of medical facilities in India and inflated cost of treatment, most of the medical care ofthe
chronic patients were taken up by the family members ( Banerjee, 1993).
Family support can be defined as a feeling that a person is cared for and valued by
other family members and that he can always fall back upon the family network in difficult
times. According to Dalal (1995), in behavioural terms, family support refers to emotional,
instrumental and financial assistance obtained from one's own family. House and Kahn
(1985) distinguish emotional support from appraisal support such as affirmation and
feedback, infonnational support and instrumental support such as money and effort. Factors
that relate to family support are family size, living arrangement, frequency of contact,
closeness ofrelationship, sharing responsibilities communication pattern and so on.
It has been found that the relationship with the family members, particularly with the
spouse accounted for the association between social support and adaptation outcomes.
Support from other sources was inadequate to compensate for the support lost in close
relationships. Family being an important component of social support, it directly improved
29

health and acted as a buffer against the effects of stress (Coyne and Delong (1986), Caplan
(1974). Many studies found that the nuclear type of families were prone to psychiatric
disorders more often than joint families (Bharat, 1991). This has been attributed to
insufficient supportive network in a nuclear family in comparison to ajoint family (Sharma
and Sri vatsava, 1991)
Family support has been found to influence health by enhancing coping effectivenes
in India and in the West, by changing the people to appraise the situation under stress.
Emotional and social support protects people from the deleterious effect of prolonged
distress. Those who have adequate support can engage in health promoting activities for the
family and seek medical help earlier than those with lower support. Support increases one's
feeling of security and lowers hislher counter-productive coping strategies, enhanced access
to information through the support group, which motivates the individual to engage in
adaptive behaviour. Feeling of obligation to those whom the afflicted individual loves
enhances motivation to adhere to difficult treatment regimen (Gore, (1985), Caplan (1968,
Caplan, Naidu and Tripathi (1986). Support gives an opportunity to the patients to ventilate
anxieties freely, to arrive at a shared understanding of the disease and to think of alternative
ways of coping. Lack of social support is found to make one susceptible to
psychopathology. Family support is found to be beneficial only if people have social skills
to mobilise help from those in the network (Dalal (1995), Hirsch (1981)).
Family support also fails in many situations due to various reasons. The family
members may be too involved and over-enthusiastic and optimistic and expect good results
to follow soon. When the expected improvement is not seen in the ill member, the family
members in their anxiety tend to blame the ill member for hislher non-cooperation. This
leads to increased anxiety and stress in the ill member leading to deterioration of health.
Thus, the family support instead of helping the patient results in negative effects. Researches
have also pointed out that family support fails in the case of disturbed families. Studies on
women and clinical work revealed that occasionally an outwardly united and stable family
might in reality be disturbed from within. Minuchin (1978) mentions about psychosomatogenic
families that were prone to physical illness due to environmental and
30

psychological stresses. These families show the sign of acute stress, anger, depression, and
apathy and bum out while managing chronic family illness. Prolonged stress not only
destroys the role of the family as a buffer but also destroys the family itself Vulnerable
families are increasing in number now-a days due to various social and economic factors.
These families instead of being support providers are themselves in need of support.
According to Dalal (1995) vulnerable families are those that are socially isolated, with no
family network, social stigma on disease and with the feeling of shame and guilt. There is
repression rather than expression of feelings, no sharing of worries and anxieties, conflicting
perception of the disease and its causation. They are characterized by a tendency to find a
scapegoat for the crisis, physical and verbal abuse and lack of trust, displaced anger,
negativism, over-indulgence or total indifference. They are less adaptable to life changes,
insulated to new information, over protectiveness and exaggerated anxiety. They are mostly
unable to resolve family conflicts, dominated by inaction, no sense of personal control, bum
out, high morbidity, family disintegration and withdrawal.
Therefore, there is the need to strengthen the family's role as a caregiver. Family's
positive involvement is vital in the treatment and rehabilitation of the mentally ill. It has
been found that patient rejection, negative attitudes and feelings towards the patient
condition are directly associated with relapse in the patients (Jonhson el. al., 1995).
Many studies have been conducted on the profiles of the mentally ill to understand
the pattern whIch may help III dealing with their illness. The study by Godbole on socioeconomic
backb>Tound of neurotic and psychotic patients revealed that most of the patients
who belonged to poorer, less educated classes, (class three and class four of a five point scale
of social class) revealed that heredity was a significant factor in mental illness. The
differences in types and multiplicity of stresses corresponded to the severity of mental
illness. Broken homes, step relations, prolonged puberty stress, birth order and absence of
male child were some factors in the family background of most of the mental patients.
31

The study found that adjustment to social surrounding was good in the primary as
compared to secondary groups, Females showed better adjustment than the males. All the
parents of the patients seemed to point to the existence of at least one type of ress such as
sexual, jobs or relational frustration, childhood calamities, physical, marital problems,
deprivation due to death, confiictsiTrpliIlIaty anduther groups and heredity problems in theiI~
life. Referral for the patients was mostly families followed by self-referral. Most poorer
classes had tried magical cures, quacks and very few, - psychiatric treatment for the illness
(Godbole,1974).
Prakasi et.al., conducted a study on biosocial characteristics of the mental patients.
It revealed that mostly the females suffered from schizophrenia or depression and males
from obsession. The age range of the patients were 20-39 and most of them had been
married. Their educational level was up to pre-school level. Among the males most were
in service and the females housewives. A majority hailed from the urban areas. The period
of illness was less that twelve months in most cases. Most of them had both or one parent
alive. The study found that the mother role of the women demanded time and energy from
her leading to weakening of functional relationships especially so for a mentally impaired
woman. Family played a major role in socialising the members. The study suggests a probe
into the biosocial factors of the mentally ill to get more inSights (Prakasi et. al., 1973).
A study on case identification and management found that serious psychoses was
about Ipercent in the community and that the psychotic patients were known to the general
public by and large and identification was easy by enquiring the key informants with the use
of vib'Tlettes.
It was found that 12 per cent of them suffered from illness for more than one year
and 98 per cent ofthem were having disability of a moderate to severe degree stressing the
need for public health importance. A majority ofthem had had no treatment and the rest had
undergone treatment without psychotropic drugs. Some had undergone crude indigenous
methods of treatment. Reasons for seeking help were related to occupational disability. The
treatment was resorted to only after many home visits by the research team. Those engaged
32

in agricultural work dropped out of treatment. Only after assurance from the professionals,
of encumbered support that the treatment was accepted.. Failure to seek treatment was
mostly because they felt the patient was alright or because the doctor was not available or
there was no money.
The authors concluded that there were many with mental illness in the rural areas and
they sutfered silently. They did not take treatment even if it was available due to the social,
cultural and physical limitations. Transportation problems and reluctance of villagers to
leave their surroundings demanded that the services be decentralised and there be
involvement of basic health worker in mental health care. Since the basic health worker
lived in the same place and spoke the same language, he had greater contact with the
villagers and his involvement was highly rewarding for the families and society (Murthy et.
aI., 1986)
A door to door survey conducted showed that the lower socia-economic classes had
a Significantly higher rate of mental disorder. The study found that an uprooted community,
which was striving hard to improve its socio-economic status, was more prone to suffer from
stress dependent mental disorders than a native born community ofthe same socio-economic
class. The women in the uprooted community suffered from hysteria and psychosomatic
illnesses, which was not the case with the native-born community women. High levels of
aspirations of the unsettled community placed the people under anxiety and stress resulting
in mental morbidity (Nandi et.al., 1978).
Studies on the institutions of mental health care and the trends
The changes in the social environment are often related to the changed patterns of
mental health. In the West (UK), a study reveals that there has been a decrease in the
number of patients treated in the hospital since the second world war and increase in the
number of cases visiting the general hospitals and in the out-patient care units. There was
increase in the cases going for community mental health care. But there was also an increase
in the admission to hospitals for treatment among the aged group. People going to hospital
33

for treatment for minor disorders like depression, neurotic disorders, paranoid acts and
anxiety states had also increased. The authors conclude that psychiatry had become a widely
accepted discipline and complementary services had grown in the name of nursery and
outpatient care. The author points out the contrasting picture in Japan where there was an
increase in hospitalisation (Hafner, 1982).
Community care which gained significantlyin the 70s and 80s in the West is now
gaining importance especially in the case of mental illness in the developing countries as
well. The community care model proves to be more effective in dealing with the problem.
A study on the working principles of a community care model conducted in Croatia
included an extended therapeutic community of not only the family, but also fellow workers,
friends and neighbours of the mentally ill. There was an attempt at co-operation and
participation of the community and removal of stigma on mental illness. Understanding
mental illness as a problem resulting from mal-adjustments was stressed and focussed on
improving relationships of patients with their environment, encouraging harmonious and
congruent communication in the therapeutic community stressing the distribution of duties,
rights, sacrifices and limits. This model was successful in removing the stigmatisation of
mental illness. It was found that due to involvement of family and friends there was a
reduction in the absence of the patients from work and reduction of patients retiring from
work. Resistance did come from families because of fear that the patient might be sent back
to them and felt threatened by the illness of the patients. In spite of these fears, the study
concluded that this type of mental health care proved to be inexpensive, efficient and
effective (Brajsa, 1985).
Community based rehabilitation is a very effective method of dealing with the mental
patients especially in a country like India, where there is general Ia.ck of expert resources.
A study was conducted on the introduction of mental health component in an ongoing
Community based rehabilitation (CBR) programme for physical illness. In order to see the
feasibility, a study was conducted in the community regarding the perception and response
of the society to mental illness. It found that the community tolerated the erratic behaviour
of its mentally ill citizens remarkably well as long as the individual was not aggressive and
34

assaultive. The society seemed to give high premium to the individual's capacity to work
and earn a living. As long as the disabled person was able to provide for his family, any
behaviour abnormality was tolerated. In the case of acutely ill member, the community first
called upon the traditional healers and resorted to psychiatric help only if the member did
not respond to natural healing. The study suggests that the role of traditional healer must be
recognised and also found that the community rehabilitation worker could very well take on
the load ofthe component of mental health, given proper training (Nagasami, 1990).
A study conducted on the usefulness of self-help groups in LIonduras, a Central
American village, characterised by poverty, unemployment, overcrowding, very poor health
care, where mental health awareness programme was implemented revealed that self help
groups formed there brought people together and seemed to improve the mental health of the
population. The researchers stressed that in a country where very few mental health
personnel are present, the only possibility of change lies in the multiplier effect achieved by
spearheading self-help groups and training local leaders to carry on the work as grass-oot
mental health specialists who initiate the project and move on to try and replicate it
elsewhere (Eisenberg, 1980)
The inter-personal relationship among the hospital staff plays an important role in the
treatment of the patients. Decision-making in a hospital setting was studied. The study
revealed that decision-making was mostly done by the medical personnel and rarely by the
non-medical staff and the bureaucratic system as such proved to be dysfunctional to the
hospital system. The incorporation of certain bureaucratic features forced hierarchy of
authonty and prestige into the clinical milieu. This was found to cause intra-personal
stresses and tensions that were undesirable for what was regarded as the optimum condition
for effective psychotherapy. Bureaucratic rigidities brought about dissatisfaction among the
low-echelon personnel. The findings suggest that the influence and participation in the
decision-making process in terms of the professional group membership improved the
effectiveness of the doctors. Ward policy and especially therapeutic practices were crucial
in modifying and accentuating the involvement and effectiveness of these professional
groups (Lefton et. aI., 1982).
35

The study conducted in 1983 in a South Indian city on mental hospitals shows that
all the beds in hospitals were occupied and the available bed strength was not sufficient. The
variation in bed occupancy in different hospitals was attributed to the variation in weather
and vacation in schools and other institutions stabilising the census level by avoiding undue
bed wastage and undue bed shortage. This seems to be a very difficult and complex task.
The discharged patients were voluntary and the criminals accounted for less than 1 per cent.
Most of the patients suffered from psychotic problems. Mortality rate among the psychiatric
population was higher than in the given population and there was relatively higher risk of
death among the institutionalised patients than in the general population. Follow-up patients
were live times more than the ones admitted from amongst the out-patients (Reddy et.al.,
1988).
Other findings were that more than hal f of the total expenditure was spent on salaries
and only 7per cent on medicines. Amount spent on development was nil or negligible. The
study concluded that there was encouraging improvement in the treatment procedures. Good
treatment outcome was positively correlated with the higher unit cost, higher rate of
treatment and more out-patient attendance. Thus the data reveals that the performance of
mental health care in India had improved during 1977-1983 (Reddy et. al., 1988).
Studies on social factors and mental illness
Social factors play an important role in acceptance and rejection of the mentally ill
person. The study on the social factors regarding rejection of the mentally ill by the
members of the society reveals that the visibility in the behaviour of the mentally ill did not
correspond to the societal expected behaviour rather to the pathology of the behaviour from
the mental hygiene point of view. Men were least tolerated for deviant behaviour than
women. Women were basically seen as sensitive and emotional and as such behavioural
symptoms were not recognised. Men were expected to cope with illness better than women
and so mental illness in men was more often rejected than among women.
36

The results of the study, emphasises the difficulties inherent in designating the
mentally ill and predicting others reaction to them and stresses that distinction must be made
between those defined as mentally ill by the public and those defined by the psychiatrists.
Prediction of others' reaction to the mentally ill should take into account the age, sex, race
and his or her particular circumstances and situation. (Phillips, 1980).
There seems to be a strong relationship between social isolation and mental illness
in old age. The study that probed into this relationship found that there were three groups
among the isolated, alienated, - those belonging to the same socio-economic status, the
defeated, - who attempted social adjustment in early adulthood and returned rather quickly.
Their tendency was to blame themselves for their failure and to feel sorry for themselves.
Another group was the semi-isolated who did not withdraw quite so completely from interpersonal
relationships and who blamed others for their isolation.
The authors summarized, that lifelong extreme isolation was not necessarily
conducive to the development of the kinds of mental disorder that bring persons to the
psychiatric wards in their old age; lifelong marginal social adjustment might be conducive
to the development of such disorders, late developing isolation was linked with mental
disorder. Isolation was found to be of greater consequence than a cause of mental illness
among the elderly. Physical illness could be the critical antecedent to both isolation and
mental illness (Lowenthal, 198?).
The study on societal reaction as a cause to hospitalisation describes the deviant as
someone who through a set of circumstances becomes publicly labelled as a deviant and who
is forced by the societal reaction into a deviant role and rules out that he is suffering from
a intra-personal disorder but instead as someone who through a set of circumstances,
becomes publicly labelled a deviant and who is forced by the societal reaction into a deviant
role. The societal reaction perspective viewed the deviant as someone who was victimised.
The evidence shown by Gove indicated that a majority of the persons who were victimised
had a serious psychiatric disturbance quite apart from any secondary deviance that might be
associated with the mentally ill role. He adds that the persons in the community did not
37

view someone as mentally ill if he happened to act in a bizarre fashion. On the contrary,
they persisted in denying mental il\ness until the situation became intolerable. Once these
patients came into contact with public officials, they were screened out, sorted and the less
disturbed persons were not victimised. He suggests that a person's behaviour determined the
expectation of others to a much greater degree than the inverse. He suggests that it was only
the patient's behaviour that leads to the mentally ill role. In the long run, the expectation of
others might play an important role in determining the behaviour of important persons and
such expectations should be taken into account in a general theory of mental illness. The
societal response theory has been criticised for under-emphasizing the importance of the
forces promoting secondary deviance (Gove, 1975).
Thus, the field of mental illness has been studied from various perspectives. In spite
of this fact much more needs to be explored and understood regarding the aspect of mental
illness, the societal response to mental illness, the problem faced by the families of the
mentally ill members, the avenues open for the care of the mentally ill and the trends taking
place in the field of the mental health care system. The field of mental health is a
combination of various fields of studies, Psychiatry, Psychology, Sociology, Social work,
Social Psychology and so forth. It IS a complex subject matter and needs to be approached
from an inter-disciplinary point of view for a better understanding.
38

Chapter Two
MENTAL HEALTH CARE: A HISTORICAL PERSPECTIVE
"The great confinement of the insane" as Michael Foucault aptly calls it, began in the
17th century. "A date can serve as a landmark, the decree that founded in Paris, the Hospital
General"(Foucault, 1967).
Foucault describes the birth of the mental hospital, thus: 'The classical experience
of madness is born. The great threat that clawed on the horizon of the 15th century subsides.
The disturbing power that inhabit Bosch's painting have lost their violence. Forms remain,
now transparent and docile, forming a cortege, the inevitable procession of reason. Madness
has ceased to be -at the limits of the world of man and death-an eschatological figure; the
darkness has dlspersed on which the eyes of madness were fixed and out of which the forms
of the impossible were bom Oblivious falls upon the world to a point beyond, on its strange
voyage; it will never again be that fugitive and absolute limit. Behold it moored now, made
fast among things and men. Retained and maintained. No longer a ship but a
hospital'.(Foucault, 1967).
In the 17th century, to be considered mad, it was enough to be abandoned, destitute,
poor, unwanted by parents or society. The individual was committed to the hospital not
primarily to receive care but rather to ptotect society and to prevent the disintegration of its
institutions. All abnormal behaviour was seen as an act of devil and 'against God'.
Hallucmations were seen as communications with the Satan and Christianity approved
specific sanctions to kill them. The descriptions of 'witches' were mentally ill
persons.(Alexander and Salanick, 1967, Deutsch,1937).
In the next phase, all abnormal behaviour was considered criminal'. Those with
socially unacceptable behaviour were put in jails along with criminals. There were no
attempts made to view their behaviour from a different perspective.
39

Until the 17th century, the method of dealing with lunatics was to isolate them from
the community as had been done in the case of lepers and treat them as not quite human
since they were thought to be subject to forces outside human control. Lunatics were
considered as criminals. Wootton points out that a complete reversal has taken place as now
the criminals are regarded as lunatics or at least mentally disturbed (cited in Bastide, 1972).
Lunacy was attributed to supernatural causes such as the Gods, the devil and the
moon. The word lunatic (from Luna, the moon) came into usage in the 15th century and
referred to persons whose bizarre behaviour was thought to be influenced by changes in the
moon. Lunacy was seen as a critical societal phenomenon because of its potential for
disrupting the social order and the responsibility for lunatics belonged to both religious
persons and royalty. Bizarre behaviour was thought to be evil and disobedient, and lunatics
were thought to be wrong doers in league with the devil. The public attitude was one offear
and disgust.
Foucault (1967) traces the history of insanity thus: In the medieval ages, if a person
in this state were considered to be possessed in some holy or demonic way, he or she was
put on the ship of fools and sent down river for some other community to put on their health
and care budget. Such was the intolerance and extrusion that was in practice. In the 18th
century, there was a theory that the insane have to be regressed, not as child but a beast and
therefore left in cages with straw on the floor and also use them for public entertainment.
Later, the insane were regarded as perverse and were manacled
During the 17th and 18th centuries, most patients were treated and housed in an
inhuman way and this changed. Known as the moral treatment, this change consisted of
social and rhetorical refonns rather than innovation in medical treatment or alterations of the
basic social dynamics and functions of the asylum.
The demonological conception of the causes of human behaviour gave way to more
rational ones. In the 'age of reason', disputes revolved around whether man's behaviour was
to be understood on the basis of biology or environmental experience. Foucault observes
40

that in the renaissance, madness was present everywhere and mingled with every experience
by its images or its dangers. During the classical period, madness was shown, but on the
other side of the bars; if present, it was at a distance, under the eyes of reason that no longer
felt any relation to it and that would not compromise itself by too close a resemblance.
Madness had become a thing to look at,-no longer a monster inside oneself, but an animal
with strange mechanisms, a bestiality from whIch man had long since been suppressed.
(Foucault, 1967)
The word insane (in=not, sane=health) came into use and accompanied the
assumption that insanity was an illness or disease of the mind. With the rise of the medical
profession, insanity became part of the medical domain. The demonological model was
under challenge; the medical (disease) model prevailed as the preferred system for
explaining and clarifying the behaviour of lunatics.
In the 19th century, the focus shifted from' evil'-' ill, in a way people are not 'bad' but
. mad' or 'insane'. The healing hand of humanism replaced the rigours of religious
punishment. The ill were looked after in more humane surroundings at that time called
'asylums,. A statement in the early 19th century reflects this humane approach .
. Moral treatment consists in removmg patients from their residence to some proper
asylums and for this purpose a calm retreat in the country is preferred, for it is found that
continuance at home aggravates the di~ease as the improper association of ideas cannot be
destroyed ... hospitals are the only places where insane persons can be at once humanely and
properly controlled (Deutsch, 1937).
These institutions, though a significant advancement, were also known to be place
of human exploitation and abuse. Clifford Beers (1921), an inmate of asylums for many
years, through his work 'The mind that found itself raised the consciousness of the
community and helped to promote better care for the mentally ill. As a reaction to this, the
mental-hygiene movement was started, a major progression from illness to wellness. This
public awareness also started the preventive psychiatry movement.
41

Goffman treats asylums as total institutions and describes thus: 'Total institutions
are social hybrids, part residential community, part formal organization and therein lies the
special sociological interest. These establishments are the forcing houses for changing
persons in our society. Each is a natural experiment typically harsh, on what can be done
to the self' (Goffman; 1961).
Sigmund Freud's Psychoanalysis marked a great tum in the field of mental health in
the 20th century. He presented behaviour and mental functions as understandable and gave
new conceptions of infancy, adolescence and characterology, thus evolving a system of
treatment where the origins of the disease could be traced. This brought a shift in the focus
from 'illness' to 'wellness' (Murthy, 1993).
Psychoanalysis as theory and treatment method witnessed the shift of mental illness
from institutions to outpatients and homes. Later half of the 20th century, witnessed growing
concerns about' individualism' as a goal for individuals and communities. The mental health
profession had to overcome the handicaps of 'odium theologicum' and 'odIUm sexicum'. The
study of factors affecting the human brain from' above' was replaced by those from' within!
and later' without'. The highly subjective and internalised approach of psychoanalysis was
replaced by the behaviouristic school ofthought of Skinner (1953) and Watson (1920) which
stresses the role of environment as a detenninant of behaviour and maintains that observable
behaviour was the essential basis for psychological investigation (Watson and Rayner, 1920,
Skinner, 1953).
The intrapsychic theories of psychoanalysis were replaced by the learning theories
of Skinner and Watson, a mixture of biological and social theories. The outcome was
'behavioural therapy' as a method of treatment with specific applicability to a variety of
human emotional problems (Skinner, 1953).
Along with these developments in the field of mental health anti-psychiatry
movement started in the west. Clare traces it as follows:
42

'The anti-psychiatry movement has sprung up, the main principle of which appears
to be that mental illness is a reductive smear that observes and defiles the despairing cries
of the downtrodden and exploited against an alienating and dehumanised society.
Psychiatric intervention is portrayed as a violent assault perpetuated under the guise of
treatmentam:!-the-psychiatristis-deemed1:o be an agentof the dominant politicat order and
an agent of repression and of power. Anti-psychiatrists demand the abolition of existing
psychiatric institutions and insist that psychiatrists either acknowledge their true role as
society's police or become agents of personal and social change' (Clare, 1976).
In the last twenty years, there has been a shift to the social origins of mental health
and mental illness. The dominant theories are of life stress, social support, social network
and family life. Murthy (1993) remarks that it is interesting to note that there is much
discomfort to view the social roots of mental health and mental illness, probably due to the
high premium placed by western thought on individual independence as the only desired
goal for all ..
The association of life stress, events and illness onset has been a part of folklore.
Recent studies indicate that these observations may be another indication of folklore
becoming folk wisdom (Holmes and Rahe, 1967). Many studies have shown that
bereavement causes life stress resulting in onset of diseases. There is accumulating evidence
about charged endocrinological and immunological functions during bereavement pointing
to the possible mechanisms involved in the vulnerable status (Hall, 1990).
A related aspect to the theory of life stress is the social support and social network.
Durkheim, more than a century ago, recognised the importance in understanding the risk of
suicide. He maintained that, 'There is a preservation of individuals both men and women
by marriage, but after a certain age, it is less due to marriage than to children. Childless
women do not enjoy the co-efficient of preservation but on the contrary suffer from coefficient
of aggravation' (Aron, 1980). The recognition ofthe importance of social support
and social network by Durkheim led to many studies on the role of social networks.
43

Many studies have been made on social ties, family interactions and social supports
(Mechanic and Aiken, 1986, Brown and Birley, 1972). Results of these studies have shown
that high mortality occurs among those with fewer social ties and recurrence and chronicity
of illness occurred due to non-availability of social support.
The trend is also towards biological explanation of altered states Qfmind in the case
of trance and possession and also the psychological states following disaster experience.
Trance and possessions are believed to be culturally defined expectations and learned
techlllques for narrowing and focussing attention as in hypnosis .... this special state of
organization of brain may underlie a wide spectrum of trance states. It is believed that if
mdividuals are trained under special circumstances, they can function at different levels of
the brain organization as in the case of those individuals in trance. The field of mental health
has thus travelled a long way and is exploring into new fields of thought in order to
understand the human behaviour.
Evolution of the Indian concept of Mental Health
In India, mental illness has been viewed popularly as an inherited idiosyncrasy or a
family· curse', or a life-long affiliation with near supernatural origins and consequently, in
this view the treatment falls beyond the realm of severe rationality. In such a context, the
path from mental illness to mental health has been long, arduous and conflict ridden. (Mane
and Gandevia, 1993).
In India, the approach to health encompasses mental hannony, which is often equated
with spiritual hannony. This view is used to advantage in the promotion of mental health
in India. This is relatively free from the western obsession of institutionalisation and
therefore, more in line with the current global thinking on deinstitutionalisation and positive
health promotion. The view is more psycho-social than bio- medical which is a positive sign
of being more holistic.
44

Wig summarises the Indian concept of mental health as follows: 'Indian culture has
always attached great significance to spiritual life, The tenn spintual IS of course not
identical with the tenn mental, but both recognise the value of inner mental life and
experiences. In India, the tenn health is usually not confined to physical state. In any Indian
definition of health, there is always reference to mental hannony and potential for spiritual
growth. The present day tenn mental health is European in concept and origin. There is no
exact equivalent of the tenn mind in Indian languages because the differentiation of 'body'
and 'mind' has never been important in Indian philosophy and it has been in modem
European thought. Thus, when we speak of' mental health' especially positive mental health,
not merely the absence of mental disorder, the average Indian will always perceive in it an
underlying reference to spiritual development. Understood in this way, mental health is very
important for him, is something to which he attaches great value; he is willing to spend time
and resources in pursuit of it' (Wig, \990).
Indian philosophy attaches great importance to spiritual dimensions of life. There
are repeated references in our religious texts on self-realisation, detachment of material
things and search for spiritual meaning of life. Four themes can be identified in the area of
Indian philosophy. Firstly, there is a rich knowledge available in the classical texts ofIndia.
The ancient sages categorically stated that in the ultimate analysis, selfishness on the
psychological side and starvation on the physical side are responsible for disorganization in
the individual and society alike. This fact stands true till today and fonns the pivot around
which psychiatry revolves. Conception of levels in the nervous system, their integration in
health and disorganization in disease was in a very general manner, anticipated in the
SANKYA system. Problem of consciousness is dealt with in a penetratingly analytical
manner in Mandukya, Chandodya and Prasna upanishads. The Yoga Vaishastha, Sankara's
Vivekachudamani, the commentaries on various Darsanas by Kumarila Bhatta and Appayya
Dikshathar's and Buddhists' works are rich store houses of learning about psychological
medicine (Murthy, 1993).
Secondly, there has been a focus on the cross-cultural considerations of dynamics in
tenns of personality functioning. Neki (1977) refers to the limitations of using dependence-
45

independence as developmental bipolarity and suggests the value of dependence as a
concept. He points out that though independence may be prized as a socio-political ideal,
as goal of individual development, it is not much cherished. He rightly remarks that the
Indian culture tends to foster dependence right from birth. He also refers to the implication
for therapy, especially, psychotherapy (Neki, 1977). Others have also examined the
prevalence of mental disorders among different social groups with focus on the role of social
stress and effects of modernisation (Chakraborthy 1990).
Thirdly, there has been a stress on the use of traditional concepts for therapy. The
most significant contribution has been the work of Vahia and others using psychophysiological
therapy based on the concept of Patanjali for the treatment of neurotic and
psychosomatic disorders. The results have indicated that Patanjali system is useful in
treating psychoneurosis and bronchial asthma. Similarly, concepts of the Gila are also used
in psychotherapy. Yoga and meditation have also been used successfully in therapy
(Vahia,et.al.. 1973).
Fourthly, there has been a focus on the role ofthe family in therapy (Murthy, 1993).
In international literature, the initial phase saw the family as the causative factor for the
illness. The second phase focussed on the interaction of the patients and family. The current
phase takes into consideration the 'trauma' ofliving with a chronically mentally ill member.
In the Indian context, family has always been treated as the primary care giver for the
mentally ill. But with the changing role in the structure and function of the family, there has
been a stress on the need for active consideration of mechanisms and measures of keeping
the family as an important source in mental health care (Bhatti, 1980 and Murthy, 1991)
Kakar brings out a corollary between Yoga and Freud's psychoanalysis. Freud in
1897 suggested an intrinsic antagonism between man's individual demands and the social
restrictions of the culture. Kakar describes yoga as consisting of three phases, preparation,
integration and meditation. First step is ethical and physiological phase, the second phase
IS the first step in transformation of the chitta and third phase is called the samyama. These
three phases involve eight steps, viz., yama. niyama. asana. pranayama, pratyahara.
46

dharana. dhyana and samadhi. The ethical preparation consists of the first two steps yama
and niyama, rules for every day living without which one cannot become a yogi: nonviolence,
truthfulness, non-stealing, continence (control of one's feelings, especially in sexual
matters), cleanliness, austerity, study and so forth. The Hindu mythology prescribes "Each
man must begin where he stands, must learn how to control the things that are neart:~1 to him
The body is very near to us, nearer than anything In the external world" (cited in Kakar,
1982).
He further makes a comparison between the Hindu and psycho-analytic view of
mental life. He observes that the fundamental concept of the Hindu psyche is the' chitta',
'even nearer than the body'. 'Chitta is very similar to the id of the psycho-analytic model,
the part ofthe psychic organization which represents the elemental, instinctual drives of the
organism. Chitta is used in the Hindu mythology in a dynamic sense to charecterise all
unconscious mental processes. Thus, if Freud described the Id as chaos, cauldron full of
seething excitation, the concept of the chitta can be evoked through similar imagery. Some
Hindu texts draw the metaphor of a monkey, restless by nature, who drinks wine and
becomes even more restless. As if this were not enough, he is stung by a scorpion and (to
complete the image of restlessness) a demon enters him. Chitta, in its nonnal state is
compared to this monkey, drunk with wine, smarting under the scorpion bite and possessed
by a demon. In the course of everyday life, chitta is bound up with the bodily organs; it
exists in the scattered fonn of outwardly directed activity and manifests itself in the
individual's experiences of pleasure and pain as well as in the' darkening' fonn manifested
in human aggression (Kakar, 1982).
According to Freud, 'The power of the id expresses the true purpose of the individual
organism's life and the development of the individual seems to us to be a product of the
interaction between two urges, the urge towards happiness which Me usually called 'egoistic'
and the urge towards union with others in the community which we call' altruistic" (cited
in Kakar, 1982).
47

In the Hindu relIgion, the chitta is also compared to a lake of muddy water, which
sends up waves, thus hides the bottom, the']' which is visible only ifthe water is calm and
the ripples have subsided. These ripples or waves are the mental functions,- perceptions,
inierence, delusions, dream, sleep and memory- all of which have their ultimate source in
the chitta.
Vivekananda describes thus: 'For instance, you hear a word. A word is like a stone
thrown into the lake of chitta. It causes a ripple and that ripple rouses a series of ripples.
This is memory. So it is in sleep when the peculiar kind of ripple called sleep causes a ripple
and that ripple rouses a series of ripples, - this is memory. So it is in sleep when the peculiar
kind of ripple called sleep throws the chitta into a ripple of memory, it is called a dream.
Dreaming is another form of the ripple which in the working state is called the memory'
(cited in Kakar, 1982).
Research has been done by many scholars to trace the evidence of mental illness and
its treatment in the ancient Indian systems of medicine. Varma found that symptoms of
'vatonmada' was roughly corresponding to those of Schizophrenia and Pitonmada and
Kaphonmada corresponded to Mania and depression respectively (Varma, \965). Dube
believed that valonmada, pithonmada and kaphonmada corresponded to Mania, catatonia
and Hebephrenia respectively (Dube, 1975).
The term 'unmada', denoting insanity first appears in the metrical passages of
Atharva veda believed to be written around 1500 B.C. By the period of the Samhitas, a
thousand years later, the word unmada underwent a change and came to be used as Unmada
(Ramu et.a!., 1988). Differentiation of Unmada into clinical sub varieties occurred at the
same time. No texts are known to have been written exclusively devoted to mental illnesses
and their treatment. Psychiatry, considered as one of the eight appendages of Ayurveda is
covered under Unmada and Bhootha Vijnaneeyam in most of the general works where a
portion of the text deals with specialty.
48

In the vedic age ranging from 1500 B.C. to about 800 B.C, symptoms of many
diseases were described and insanity, unmada was distinguished as an ailment affecting the
mind. Unmadas, according to them were of two kinds- one produced as a result of
consuming unwholesome food and the other as a result of one's wrong doings. Medicines
were indicated for the former and atharvas (incantations for the latter (Namboodiri,1989). -
Atharva veda deals with Bhootha vidya in great detail and prescribes remedies in the form
of drugs, magical spells and charms. Four different types of treatment are mentioned.
Atharvas (spells and incantations, Angirasah (herbs and diet), Daivika (invocations) and
oshadhis (compound medical preparations). These have been compared to present day's
psychotherapy, naturotherapy and drug therapy. Curse as a cause of insanity is described in
Aithavya Brahmana. Invocations to God to cure insanity are seen in Thaitreya Samhitha.
The vedic period foresaw two doctrines which were later to be cardinal theories of
Ayurveda. These are the Pancha Bhutha doctrine and the Tridosha theory. The hymns say
that the body is made of five elements constituting the universe at large; to which they
ultimately return after the body perishes. The tridosha theory postulated that health is the
result of an equilibrium state of the three Doshas (humors). The specific relevance of these
two theories in Psychiatry is that the Panchabhutha theory is also a theory of personality
explaining its origin and nature and also accounting for the individual differences. The
Tridosha theory attributes a physical basis for mental illness, which maintains that, the three
humors, vatha, pitha and kapha, translated generally as the wind, bile and phlegm are
responsible for both health and disease in man (Namboodiri, 1986).
In the Upanishadic period which followed the vedic age, the spiritual self became the
center of study. During this period ranging from 800 B.C to 600 B.C. the seers of the
upanishads dug up further deep into the inner consciousness of man, mind and its faculties,
the different states of consciousness and the nature of self (Namboodiri, 1986).
Ayurveda was divided into eight specialties and Psychiatry rose to the status of a
specialised discipline in the Samhitha period. Charaka suggested that only an expert in the
field of mental illnesses (Manasa Roga Bheshaja Vetti) should treat the mentally afflicted
49

(Ramu, et.al., 1985). Rao (1978) observed that there was no Sanskrit equivalent for the
terms 'Psychology' and 'Psychiatry' in Ayurveda Bhootha vidya and Grahabadha (the study
of supernatural influence in the causation of illness) were merged with psychiatry as
possession by these supernatural elements were considered as one etiological factor. The
terms Grahaand Bhutha (literally meaning the demons and spirits which by possession
causes disease) which indicate that the man is "somehow or other" afflicted with an illness
and that "something or other" has happened to the individual and need not predict a
supernatural event (Rao, 1978).
Ayurveda recognises personality types and correlates them with predisposition to
specific psychiatric syndromes. Depending on the dominance of three 'Gunas', three main
types of personality are distinguished with several sub types under each: The sattwika type
characterised by high moral standards, truthfulness and lack of conceit, the Rajasa type with
five sub types, who are passionate, impulsive and ambitious and the Tamasa type with four
sub types who are ignorant, lazy and fickle minded. Based on the preponderance of one of
the three congenital factors in the body (humors) there was another way of classifitation of
personality which anticipated the Kretschmer's body types-the 'Vatic Prakrifhi'
(preponderance to vata) resembling the aesthetic constitution. The 'Paithic' and 'Sleshmik
Prakrithis' resemble the athletic and pyknic types (Varma, 1953).
Namboodiri (1986) observes that in Ayurveda, illnesses were divided into two kindsphysical
and mental. Psychoses were called unmadas and were described as
llbhayadhishtidha Vyadhi (originating from both body and mind). They occur as a result
of vitiation of Tridoshas but are present with prominent mental disturbances. They are
relieved only when the Tridosha balance is restored. Equivalent to the three "Physical"
humors, Charaka postulated two mental humors (manasadosha: Rajas and Tamas).
Exogenous factors affect the manasa doshas initially and provoke them which in tum upsets
the Tridoshas and cause symptoms (Namboodri, 1986).
Charaka defmed unmada as an unsettled state of mind, understanding, consciousness,
perception, memory, desire, character, behaviour and conduct (Ramu el.al., 1988). Unmada
so

is divided into Nija (endogenous) and Agathuka (exogenous) varieties depending on whether
the etiological factors are intrinsic (the three humors) or extrinsic (exogenous factors). Thus
the Nija Unmadas are Vathonmada, Pithonmada and Kaphonmada and a fourth where all
humours are simultaneously provoked.
Thirty seven etiological factors were listed as endogenous and fourteen as exogenous
in one study (Mahal et.al., 1976). They vary from consumption of unwholesome food to
volitional transgression (Prajnapradha) and from physical traumata to supernatural
possession. It was believed that people who wereare more prone to illness were those who
were cowardly and faint-hearted; who violate the principles of diet and general code of
ethics, etc. It was believed that the vitiated humours ascend up and obstruct the conveyors
of manas (manovaha srothas) affecting the brain and disrupting its functions.
The symptoms identified are multiform and include emptiness of head, fluttering of
eyelids, ringing in the ears, hurried breathing, siallorhoea, diminished appetite, indigestion,
heart-bum and lassitude. The affected person IS anxiety stricken, bewildered and dejected,
becomes preoccupied with in-auspicious thoughts. He has frightening dreams and visions
of being crushed under the wheels of an oil press, of being suffocated by windstorms or of
being sucked into whirlpools of filthy water. Poor prognosis resulted in vitiation of all
humours in causing the illness (sanmpatha), regression to the stage of a wandering lunatic
when the patient is chased by urchins, discarding of clothes and chronicity of illness
(Namboodri,I986)
Ayurveda also offers various therapies for the cure of illnesses. Therapies are
directed to bring a state of equilibrium, 'doshasamyam' as it is believed that humoral
disequilibrium, 'doshavG/shamyam'is the cause of the illness. Medicaments, therapeutic
procedures, drugless method of treatment, (AdrG/vyachikitsa) like psychotherapy
(.~twavaJaya), counselling, recreational therapy, prayers to propitiate a God etc. are used
singularly or in judicious combination. Other therapies for radical correction of an upset
humor are vasthi (medicated retention enemas), virecluma (purgation), Vamana (purification
by giving emetics), Nmya (instillation of medicated drops deep into the nasal cavities) and
51

Raktha Moksha (vene suction) These five are together cal\ed as the Panchakarmas in
Ayurveda.
Mahal and others report that Ayurveda prescribes about 60 different therapies along
with their indications. Prajnapradha (misuse of intellect, wilful wrong doing, vocational
transgression, either by omission or commission) is considered as an important cause for
mental il\ness. Psychotherapy directed to restore Judgement and confidence and to remove
guilt feelings, imparting proper knowledge, etc. are indicated in such instances.
Intimidation, terrorisation, coaxing, exhilaration, pacification etc. are to be considered as
attempts to modify behaviour to be compared to the modem techniques of behaviour therapy,
even though some methods suggested would appear cruel and inhuman (Mahal et.al., 1976).
The treatment methods are dealt under three categories,- Daivavyapashraya chikitsa,
Yukthivyapashraya and satwavajaya. The first consists of propitiating Gods through
prayers, incantations, wearing herbs and gems on the body, performance of sacrifices,
oblations and offerings, undertaking vows, fasts and pilgrimages, etc. The
Yukthivyapashraya chikitsa is the drug-diet therapy and Satwavajaya corresponds to
occupational and recreational forms of treatment.
Around Samhitha period there emerged another system of treatment known as
Siddha Vaidya. The dravidians were in the forefront and were chiefly responsible for the
development of this branch of medicine. Siddha Vaidhya follows the tridosha theory and
maintains that an imbalance of humours precipitates illness. There are clinical syndromes
corresponding to Schizophrenia, mania and depression. "Kirukku" recognised by the
practitioners of Siddha vaidya in Tamilnadu resembles Schizophrenia and is of 18 types
(namboodiri, 1986).
The treatment methods in Siddha Vaidya are feeling the pulse (Nadijana) and
examination of urine (Moothra pariksha). The treatment methods mainly consist of variety
of metals and their salts, along with herbal medicines. The earliest text book of Siddha
52

Vaidya. Rasahridayathantra by Govinda Bhagavatha Padacharya dates back to 8th century
A.D.
The unani method of treatment became popular in India following the advent of the
Muslims. Mental illness was divided into seven varieties by Najabuddin Unharnmed among
which Sauda-a-tabee resembled Schizophrenia. When Sauda became chronic. it was called
lanoor. Treatment measures consisted in placing the patient in placid and restful
environment, kind and sympathetic nursing, nutritious food and medicines including
stimulants. Bleeding and purging were prescribed in the early stages (Varma, 1953).
Belief in magico religious methods of treatment, which is prevalent even today, dates
back to the ancient period. Use of charms, incantations and talisman are believed to be more
ancient than religious practices. The earliest texts dealing with this aspect of magical
treatment is the atharvanaveda which contains the texts of various hymns and formulae.
Drugs are often used along with formulae during incantations. They are believed to have a
complementary action in affecting cure. There are differences observed between the Aryan
and Dravidian systems of incantations. Hymns from Sanskrit texts are used in the former
and in the latter, formulae in vernacular language are used along with sacrificial killing of
animals (Namboodiri, 1986).
Namboodri notes religious methods of treatment dating back beyond recorded
history. Paying obeisance to God for material benefits and for repelling catastrophes still
continue in the Indian culture. The sick and healthy visit temples. For the sick, the priests
offer prayers and prescribe vows and penances which the patient have to undertake. Rice
and pudding are given to the patients after they are first offered to God. Smearing the body
with sandalwood paste and sacred ashes, sprinkling holy water on the head and body and
anointing patient's eyes with holy oil are other things prescribed by the priest. Medicinal
preparations are occasionally used. One temple in Kerala routinely administers to the
patients a medicated oil with strong emetic properties. Ghee medicated with Ayurvedic
drugs are often given in many temples. Oblations are offered in some temples by the
patients, in the form of "Kuru/hi" which is a red liquid mixture of turmeric and slaked lime
53

symbolically representing blood. Gods chiefly propitiated for the cure of mental illness are
Lord Siva (who is described as Bhoolhesa, the Lord having control over Demons and Kali
or the Mother Goddess (Namboodri, 1986).
The recognition of mental illness, classification and treatment dates back to 1500 B.C
in India. These methods are being practised even today and some of them have also been
integrated into the western methods of treatment to suit the Indian set up. On the whole, one
can confidently say that the concepts of mental illness has been well defmed by Our ancestors
even before the subject of Psychiatry came into existence. Magico-religious forms of
treatment dominates the rural scenario and these methods of treatment are sought for initially
for cure before they seek the help of a Psychiatrist (Namboodiri, 1986).
Mental Health Services in India
The history of modem psychiatry in India originated with the establishment of
mental hospitals. The mental asylums were entirely a British conception though there is a
reference to some asylums in the period of Mohammed Khilji (1436-1469). The early
institutions in the Indian sub-continent were greatly influenced by the ideas and concepts as
prevalent in England and Europe during those days. Primarily, the mental asylums were
built to protect the community and to treat the insane. These asylums were initially meant
to treat European soldiers employed with the East India Company (Sharma, 1992).
Reference to the first mental hospital was recorded in the proceedings of the Calcutta
Medical Board of April 3,1787. This asylum could not be recognised by the Medical Board,
since the person responsible for its establishment, Surgeon Dr. George M.Kenderline was
dismissed from service because of neglect of duty. Later a private lunatic asylum was
constructed, recognised by the Medical Board and rented out to the East India Company for
Rs. 400 per month. At the same time, another lunatic asylum was opened in 1795 at
Monghyr in Bihar about 400 miles north of Calcutta which was specially meant for insane
soldiers. The remnants of this building are still there at Shyamal Das Chakravarthy Road
and is known as "Paghla ghar building" (Varma, 1953).
54

During the same period in 1794, the first mental hospital was opened in South India
at Kil pauk, Madras. In 1817, an attempt was made to improve the conditions of the hospital
at Calcutta, which had between 50-60 European patients with clean surroundings and a
garden. During this period, excited patients were treated with morphia and opium, and were
given hot baths and sometimes leeches were applied to suck their blood. It was then
believed that blisters were useful for chronic patients and also helpful for controlling their
periodic excitement. During the same period, another lunatic asylum was opened in Dacca,
which is now part of Bangladesh. Music as a form of treatment to calm down excited
patients was first tried during that period in this hospital (Varma, 1953). Hospitals were also
opened at Patna and expansion of the Madras Hospital was undertaken. The first hospital
in the western coast was started at Colaba in 1806.
After Lord Cornwallis's rule in 1793 till 1857, there was no growth in the mental
hospitals in India except in Bombay, Madras and Calcutta. In 1858, the most significant
development was the enactment of the first Lunacy Act known as Act. no.26. It gave
guidelines for the establishment of mental asylums and also set the procedure for admitting
mental patients. The Act was later modified by a committee appointed in Bengal in 1888
which gave elaborate instructions and guidelines for admission and treatment of criminal
lunatics (Sharma, 1992). According to Sharma asylums for the insane were originally built
in India as in other countries, when it was considered advisable to segregate those who by
reasons of insanity were troublesome and dangerous to their neighbours. The asylums were
thus places of detention. As medical supervision was considered necessary, these were given
over to medical management in the event of an illness to inmates. Segregation of buildings
and supervision were entirely British conception (Sharma, 1992).
After 1858, many changes in administration and health care resulted in opening more
lunatic asylums in the eastern parts of India in Orissa, Bengal and Bihar. There were six
asylums opened at Bhowanipore in Calcutta, Patna, and Dacca, now in Bangladesh,
Berhampur, Dulanda and Cuttack. In the same year, Assam was separated from Bengal and
a new asylum was opened in Tezpur.
55

In the south, in Madras Presidency, new hospitals were opened at Waltair and
Trichhirapally and a new hospital was also opened for 145 European and Indian patients in
Madras city in 1871. In the western part of India, in Bombay Presidency, a similar expansion
was noted and six such institutions were opened by 1865 at Colaba, Poona, Dharwar,
Ahmedabad, Ratnagiri and Hyderabad (Sind). Colaba was mainly meant for the Europeans
with over 285 beds and Ahmedabad had 180 beds in 1872. Similar expansion was visible
in the central provinces where asylums were established in 1872 at Jabalpur and Elichpur in
Bihar. A hospital in Benaras was started in 1854 and at Agra in 1858 and later, at Bareilly
in 1862 (Varma, 1953).
In the northern province, the first hospital was started in 1840 by John Martin
Honigberger, one of the physicians of Maharaja Ranjit Singh who is reported to have treated
mental patients in an annex to his hospital within the grounds of Raja Suchet Singh's palace.
When Punjab was taken over by the Briti,h, Hoinberger handed over his twelve epileptic
and idiots to the first civil surgeon of Lahore who was considered to have humanitarian
approach to such patients. When the number of patients increased from 12 to 85 and then
to 285 in 1863, the conditions in the hospital deteriorated and was renovated only in 1900,
a clear evidence of apathy and indifference on the part of the authorities to the needs of the
people (Sharma, 1992).
The early part of the 20th century witnessed very significant changes in the field of
mental health. The first significant change was the decision ofthe government to give the
charge of the mental hospitals to the civil surgeons, which were previously under the charge
of the Inspector of Prisons. The second change was in the recognition of specialists in
Psychiatry to be appointed full-time officers in these hospitals. The third significant addition
was the intent of government to have a central supervision of all lunatic asylums which was
contemplated in 1906 and was brought out in the form ofIndian Lunacy Act, 1912. The
other associated change noticed was the growing concern among the public about the
conditions of mental hospitals which resulted not only in the improvement of existing
56

hospital conditions at that time but also in the opening of many more hospitals (Sharma,
1992)
Under the new legislation of Indian Lunacy Act of 1912, a Central Lunatic Asylum
was started in Berhampur for European patients and was later closed after the establishment
of the Central European Hospital at Ranchi in 1918. Col. Berkeley Hill the then
Superintendent of the hospital made the Ranchi institution the foremost in India at that time.
Dr. Hill was deeply concerned about the mental hospitals and wrote in 1924,"There
is a Persian saying that there is no greater anguish known among mankind than to have many
thoughts at heart and no power of deed. This particular form of anguish must be well known
to most of the medical superintendents of mental hospitals. For how many of them longed
to raise the standard of the work at hospitals whose welfare they have at heart but for some
reason or another the power of deed is denied to them. Nevertheless in spite of many a heart
made sick by deferred hopes, every medical superintendent is probably in a position to raise
the efficiency of the hospital in hIS charge provided he can get plenty of good ideas to work
with" (Berkeley, 1924).
Due to the sincere efforts of Hill, the standard of care and treatment in the Ranchi
Hospital improved and due to his persuasion, the government changed all the names of the
mental asylums to mental hospitals in 1920. Sharma notes that there was recognition of
occupational therapy and other measures during the period after 1920. The need for
associating social scientists in the diagnosis and management of psychiatric patients were
generally realised. The first efforts to train psychiatrists and psychiatric nursing personnel
were made during this period. As a part of social awareness, initial attempts to establish
direct links with the patients' families were made in the form offamily units (Sharma, 1992).
In 1946, CoI.M. Taylor, the then Superintendent of the European Mental Hospital, Ranchi,
as a member of Health survey and Development Committee known as "Bhore Committee"
gave his report based on his survey on mental hospitals. According to his report, there were
at least 19 hospitals with bed strength of 10,381. His concluding observations were as
follows:
57

'The majority of the mental hospitals in India are quite out of date, and are designed
for detention and safe custody without regard for curative treatment... saviour of the
Workhouse and the prison and should be rebuilt. The remainder should be improved
and modernised. Bombay and Calcutta urgently require modem mental hospitals to
meet both the needs of the community and the Medical Colleges, and these should
form part of any schemes for reconstruction or expansion. There is a gross
inadequacy in the medical personnel in all mental hospitals both numerically and in
specialised qualifications. Most of the Medical Officers employed as
Superintendents and deputy Superintendents possess neither the status nor the
experience, which would justify the description of Consultant or Specialist in the
ordinary usage of that word. A mental health service is necessary with improvement
in the status, pay and conditions of service of the medical staff, with increased
opportunities for purely professional work' (Taylor, 1946).
Similarly, he also pointed out that 'the numerical and professional adequacy of
Nursing Staff and Attendants requires urgent attention'. It was observed by the committee
that the Indian Lunacy Act of 1912 had outlived its usefulness. It also suggested a need for
a Directorate of Mental Health at the Central level as well as in the Provinces.
After independence, over the years the number of mental hospitals, their bed strength
and utilization of their services, increased. An over-view of the pattern of total bed
availability and the patient turnover in the mental hospitals in this period indicates that
though the number of beds increased only marginally, the number of patients utilising the
hospital service increased manifold.
S.D.Sharma (1992) in his research study on mental hospitals in India found that there
was a steady increase in the number of people utilizing the services of mental hospitals and
this he attributed to the changing value system, urbanisation, industrilisation and family
pattern in the society.
58

Table 2.1 Number Of Mental Hospitals, Their Bed Strength, Admission, Discharge
Cases And Deaths Of Mental Patients During The Year 1951-1986
Year No.of mental Bed Strength Admission Discharge Deaths
hospitals
1951 30 10,148 5,837 5,831 471
1961 35 12,533 21,641 6,292 1,266
1971 38 18,507 32,064 31,975 1,113
1981 45 20,559 49,195 48,353 931
1986 45 20,674 54,759 53,169 922
Sources: S D Sharma (1992). Mental Hospitals In India: A NatIOnal Perspective.
After independence, there have been very few additions made to the number of
mental hospitals and no mental hospital has been closed in spite oflack of financial support.
Though the number of mental hospitals has increased from 31 in 1947 to 45 in 1987, the
number of patients treated in these institutions having increased mani fold.
Sharma observes that 'The mental hospitals in the country have curiously remained
unchanged. They remain till today a motley assortment of institutions- some offer
comprehensive care and rehabilitation, whereas most others remain the restrictive and
confirming 'asylums' in which custodial care takes precedence over therapeutic care'
(Sharma, 1992).
The post-independence era witnessed the introduction of General Health Psychiatric
Units (GHPU) in all the hospitals. These units resulted from various considerations with
mental hospitals like:
1. Inability to deal with all the mentally ill individuals.
2. Lack of desired therapeutic environment.
3. Non-availability of facilities for the comprehensive medical care.
4. Isolation of mental hospitals from general medical services.
S. Professional isolation for the psychiatrists.
59

By 1970, about 90 psychiatric clinics in general hospitals were operative in India.
It was observed that the treatment in general hospital psychiatric clinics, reduced stigma,
increases accessibility and offered thorough follow-up service and treatment of associated
physical problems (Murthy, 1982).
GHPUs were followed by the District Psychiatric Units, OPUs, as a consequence of
the Mudaliar Committee. According to the Government of India report only Kerala,
Tamilnadu and Karnataka had OPUs and the situation in other states was not satisfactory.
Only 10 per cent of those requiring urgent mental health care were receiving the needed help
with the existing services. The situation was worse in the rural areas due to the heavy
concentration of the services and facilities in the urban areas (GOI, 1990).
Public education on mental health was started in 1964 by the Indian Psychiatric
Society. The group suggested preventive mental health programme as an answer to the
impasse in the field of psychiatry. The major goals that were suggested for mental health
were defined as follows:
1. to disseminate knowledge and develop understanding of the underlying principles of
mental health;
2. to dispel ignorance, faulty beliefs and superstitions in the general public with regard to
matters of mental health and diseases and to create informed public interest in such matters;
3. to promote good mental health in children;
4. to develop the community aspect of mental health programme; and
5. to promote research and training of the personnel for mental health activity.
The group also suggested 1. Incorporation of mental health into public health; 2.
Mental health services in district hospitals; 3. Extramural activities for psychiatric hospitals
and their staff; and 4. Setting up of new voluntary organizations as further avenues for
extension of public education.
Over the years, the central points of developments have been the utilization of
community resources for mental health care. The last 100 years have witnessed a shift from
60

mental illness to mental health, from purely medical to biosocial model. The interventions
range from policies at the society level, specific drug treatment, support in crisis, utilization
of different community resources and psycho-social interventions in the form of social
support. There is also a shift from the institutions to the community, from professional to
nOll-professionals, flOm-verticat- programmes to ilftegration; public involvement and
education to destigmatise mental health care. In the last few years, there has been a focus
on educational infrastructure and welfare infrastructure to develop promotive and preventive
mental health programmes. The last 15 years of policy making in India has been on
decentralisation and deprofessionalisation (GO!, 1990).
Goldberg and Huxley rightly describe the situation of mental health care in most of
the countries thus: 'There is now an explosion of knowledge about mental disorder and it has
become possible to discern the outlines of the model for mental disorder which takes account
of findings in both social psychiatry and molecular biology. However, we have not made
corresponding progress in defining administrative and architectural requirements for meeting
the needs of the mentally ill and in most countries ofthe world services for the mentally ill,
survive on the crumbs left from the banquet of general health care. At times of scarce
resources, our services are very easy to prune. The liberation of others-clinical
psychologists, nurses and social workers from domination of the medical profession has
occurred in many countries and has been the enemy of a united service which offers the best
to patients and which commands adequate resources from society' (Goldberg and Huxley,
1992).
In India, many innovative approaches have been used to compensate for the
inadequate facilities available and socio-economic constraints. Vidyasagar (!971), in
Amritsar, involved families in treatment which was imitated at Vellore and at Bangalore
(Verghese, 1971, Chennabasavanna and Sheriff, 1977). Ayurvedic methods for treatment
of mental illness was tested by Mahal et. al.,and others in 1976. Treatment to rural disabled
people were initiated at Raipur Rani in 1976 (Wig el. al., 1982) and at Sakalwara in
8angalore (Kapur 1992, Chandrasekar et.al., 1991, Issac et.al., 1981). Training to teachers
to deal with mental health problems among students was implemented. Kapur (1975) and
61

Sethi et. al. , (1977) studied about traditional healers and their involvement in modem
treatment methods of mental health. Home care treatment programme was initiated in
8angalore by Kapur and Pai in 1983. Another breakthrough was the starting of satellite
clinics by NIMHANS, 8angalore, in 1981 under the control of Psychiatrists and social work
professional in fOUT districts of Kamataka (Reddy, 1982).
Other approaches were also initiated like mobile mental health clinics, volunteers
participation in mental health care, student volunteers in mental hospital programmes, school
teachers and students in mental health programmes, anganwadl workers in mental health
care, periodic involvement of family in the treatment of the mentally ill in hospital settings
and using social work measures in the treatment of neurotics and involvement of village
leaders in mental health care.
Murthy (1993) pomts out that the mental health professionals in India are in an
advantageous positIOn to develop programmes to match both the dictates of society as well
as the individual. According to him, the development of the concept of mental health from
mental Illness has some features, namely, a steady evolutIOn of the concepts of causatIOn and
a broaderung in the scope of mental health and mental illness-a moving away from a highly
mdlvldual orientation to a larger SOCial system onentation.
Sociology of Mental Disorder
The sociology of mental disorder is as old as SOCIOlogy itself, as Auguste Comte
was the founder of both He was as critical of doctors as he was of lawyers. He said of
doctors that 'they study the animal in us'. In other words, he said they deserve the title of
'veterinarians', rather than of 'doctors'. He was the forerunner of psychosomatic medicine
m two senses. First, in the emphasis he placed on the interaction of mental and physical
phenomena. He stressed that as man is the most indivisible of beings, his body and soul
should be studied simultaneously, so that ideas fonned about him are not mistaken or
superficial. Second, in his linking of medicine WIth the' Religion of Humanity'. He pointed
62

out that the doctor who sees in man a body is a veterinarian; the one who wishes to see both
body and soul must necessarily tum to Sociology (Bastide, 1972)
Audiffrend, Comte's disciple, systematised Comte's theories. He produced a
coherent positivist picture of mental disorder. He says that insanity is characterised by a
two- fold' subjectivity' both logical and social. From the point of view oflogic, insanity like
the dream is a process without object whereas the scientific or positive approach is
dependent on the object. From the social viewpoint, insanity, again like the dream and the
day dream, represents the mind which has broken away from collective control, which is
given over to itself to the amorality of its inner world and the unleashing of the desires
(Bastide, 1972). In Comte's words, Insanity is the mind in a state of' selfishness', the revolt
of the individual against the humanity. The revolt against objective reality and the revolt
against altruism are not basically different, but represent the same process, the surrender of
the individual to subjectivity.
This surrender, he adds, characterises certain periods in history. Insanity has always
existed, but its incidence varies according to that period. Thus, Comte's work is not only
sociological definition of insanity but also a study of the sociological conditions associated
with its appearance. Positivism distinguishes between organic periods and periods of crisis,
according to whether solidarity between individuals is organised or whether it is in the
process of disintegration.
For instance, he explains that the Middle ages are an organic period and the age of
positivism is another. But between these there must have been a transition period when one
social structure has disintegrated because, it no longer corresponds to man's needs and a new
structure has not yet emerged. In crisis periods, such as the Reformation or the French
Revolution, the individual rebels with the aim of asserting his personal identity. This is
when subjectivity which until then was under the control, both of reality and society makes
its appearance. The increase in the incidence of insanity is related to the passing from
organic into a crisis period and develops alongside for the same reasons as 'individualism'
(Bastide, 1972).
63

Bastide (1972) observes that the curse of insanity can be said to lie, not in
individualism, which necessarily brings about solidarity, but in the lack of organization of
this new type of solidarity. From Durkheim onwards, the problem of the sociological origins
of insanity is formulated in terms of a new concept' social anomie'.
According to Bastide (1972), Morel stands in opposition with Comte and Audiffrend.
He relates the rise in crime, a phenomenon of social pathology to the rise in mental disorder,
a phenomenon of mental pathology. He is of the view that there is a connection between the
two. He adds that man's nervous system is the weakest part ofthis organism and can easily
be intoxicated by malaria, lead poisoning, alcohol, etc. thus producing insanity. According
to him, society is composed of individuals, the intoxication of whose nervous system can
lead to feeble rnindedness, sterility or criminality. He is of the view that the degeneration
of individual leads to the degeneration of the race and eventually to the end of civilisation
itself. He observes that people known as 'primitive' are merely people whose progress has
been halted or who have regressed owing to their unhealthy environment and the illness
caused by it (8astide, 1972).
Comte (1849) was interested in the influence of social factors on mental illness,
thereby founding-sociogenetic theory. On the other hand, Morel was interested to show the
effects of mental illness on the society and thus established a biogenetic theory of social
pathology. He wrote his theory based on the dogma of immutability of the species and the
beliefthatthere existed a normal type of man, but this type could be affected by disease and
corrupted. He was of the view that the disintegration of the nervous system was the cause
of the disintegration of social ties (Cited in Bastide, 1972).
The concept of degeneration was replaced by the concept of regression. According
to Jackson in Psychiatry and Ribot in psychopathology, the disintegration of mental
functions follows the opposite direction to evolution- that is, the most highly evolved levels
are the first to be impaired and the most automatic the last. Richard drew sociological
conclusions from this theory and pointed out that the sickness of society is the consequences
64

of regression or disturbances of the will and the personality. Ribot describes that the
increase in the number of 'amorphous' and' unstable' people is incompatible with a social
system which requires increasing determination from the individuals (Bastide,1972).
Thus, sociology was split into two schools, one that looks for the social factors in
mental disorder and can be traced back to Comte: the second school rejects social factors and
tries to define the social effects of the increase in mental illness and can be traced back to
Morel.
Levy-Bruhl distinguishes between two states of mentality, the pre-logical mentality
and the logical mentality. He was of the opinion that it was impossible to form an idea of
the perception, judgement and actions of primitive man through the intermediary of our own
ways of thinking and feeling. He suggests that strictly objective studies should take the place
of interpretations based on western thinking. He suggests the same solution to psychiatrists
to study the 'morbid consciousness' 'as a psychological reality in its own right which is
irreducible to our own experience and therefore cannot be reconstructed on the basis of
normal states and processes of consciousness' (cited in Bastide, 1972).
Blondel's approach was similar and he was in contradiction with Ribot in his view
of the difference between normal and pathological. He was of the opinion that 'the
difference is not quantitative but qualitative; morbid consciousness is not a distortion of
normal consciousness, but something quite different. Normal consciousness is capable of
conceptualisation and is, therefore socialised, whereas pathological consciousness is
incapable of organising itself according to our' normal' logical frameworks, of fitting
coenesthetic disturbances into the mould of current language. It is desocialised
consciousness' (Blondel 1914, cited in Bastide, 1972).
Blondel and Comte have much in common in saying that insanity is the triumph of
pure subjectivity in its dual departure from reality and from social life. Blondel goes a little
further to give a methodological rule: it is impossible to interpret the pathological through
the normal.
65

The most significant contribution to the field of sociology of mental disorder came
from Durkheim's functional approach. He discovered 'useful' functions for something as
apparently as crime and consequently introduced the abnormal into the basic structure of
society. He was not in favour of sociogenetic theory of psychic disturbance and attributed
mental disorder to the psycho-organic causes. He gave the sociology of mental disorder a
new concept that is widely used, anomie.
He gives two different definitions of anomie, one that is objective that is found in
'The Division of Labour in Society': anomie is characterised by the absence of control and
therefore of stability and regularity in the relations between different social' functions', this
results in conflicts between organisms which are theoretically inter-dependent and the other
subjective that is found in 'Suicide': anomie is characterised by a lack of control over
passions, unfettered desires, impatience with rules and regulations, irritation and disgust,
according to whether the period is one of prosperity or depression. Durkheim did not apply
this concept of anomie to the study of mental disorder as he thought they were a result of
physiological and psychological situations. The concept occupied a central position in the
study of social origins of psychic disturbance only when it was taken up by American social
scientists (Durkheim, 1897)
Around the same period as Durkheirn, Pierre Janet put forward the idea of psychic
tension that took him from psychiatry to sociology. At the end of the nineteenth century,
there were two movements; one starting from Sociology and moving towards Psychiatry and
the other starting from Psychiatry and moving towards Sociology but nevertheless reaching
the same conclusion that there is a social dimension to mental illness.
Janet put forward his idea of psychic tension in two ways: Quantitatively by the
amount of psychic resources and qualitatively by the hierarchical position of the activities
of which a person is capable. According to him, our civilisation is an exhausting one, things
change rapidly and a heightened tension is required to adjust our behaviour to the elements
in our situation that is new to us. He adds that the mentally ill person, lacking in psychic
66

esources either takes refuge in solitude or, like 'Mandeline', creates a fantasy world where
imaginary people behave exactly according to his wishes (Janet, 1926, cited in Bastide,
1972).
The most important thing that Janet's theory explains is that the increase in neurosis
and psychasthenia by the growing complexity of social life. He points out that so long as the
society does not create problems which are too difficult and does not demand too much of
the individual, subjects who are disposed to psychic disorders can succeed in adapting and
leading a normal existence, that is what happens in homogenous and traditional communities
such as rural communities. But in the progressive and heterogeneous modem city,
competition and the struggle for higher economic and social status lead us rapidly to bum
up our last resources (Janet, 1926 cited in Bastide, 1972)
Sociology of mental illness also witnessed debates from the Marxists. There were
basically two tendencies, one used the concept of class struggle and alienation to bring to
light the pathogenic effect of economic conditions and the other represented by orthodox
Soviet psychiatry based on Pavlov's theory of conditioned responses. Le Guillant is of the
view that phenomenon of abnormality must necessarily be observed, in their environmental
context. He is of the view that one must take into account the total real situation and the
divisions and contradictions in the society. According to him, the first task of psychotherapy
is to change the social environment and improve the conditions of living (Guillant,1954,
cited in Bastide, 1972)
According to Bastide ( 1972), Gabel, who belongs to the second tendency of Marxist
thought based on Pavlovian theory is of the view that man's normal consciousness is
determined by his social existence, whereas morbid consciousness is extra-social and
depends on the influence of essentially biological factors. Pavlov is of the view that if two
reflexes are conditioned in a particular way, a conflict can result which inhibits them both.
He recognises the importance of conditioning and the influence of the society. He points
out that conditioning becomes complex as one progresses from animals to man because of
the appearance of speech, culture and ethical values. Thus, Pavlov is also finally led to
67

sociology; mental illness is caused by congenital deficiency or by the impact of an
environment, which is threatening to the individual, exhausts his energy, inhibits the
functioning of the central nervous system and thus liberates the subcortical or neurovegetative
functions. Thus, one can see that the Pavlovian approach and the sociological
approach are not contradictory but complementary (Bastide, 1972).
Psychoanalysis has also contributed to sociology of mental disorder in recognising
the value of sociology. Psychoanalysis was concerned with the early experience of the
patient, his childhood, relationship with his mother, father and siblings and thus threw the
attention of psychiatrists, sociologists and social psychiatrists to the importance of family
influences in the genesis of psychic disorders. It also recognised that these disorders were
caused by traumas in early childhood not only within the family but also outside and thus
leading to sociological research. Psychoanalysis, which is a dialogue between the analyst
and the patient, awakened an interest in a particular problem, the problem of communication.
Horney (1937) notes that . A prevailing sociological orientation ... takes the place of a
prevailing anatomical-physiological one' Thus, by insisting more on the defence
mechanisms than on the libido, contemporary psychoanalysis gives more importance to
sociology than the older school (Homey, 1937).
American theories of disorder could be traced back to the work ofZnaniecki's 'Polish
peasant'. Sociologists were only providing suggestions for research until the contribution
ofZnaniecki, in his study on the Polish Immigrants in the U.S.A In this study, he showed
how lack of social integration could cause delinquency and produce higher rate of mental
illness among the immigrants than that of their native country. After Znaniecki, a series of
studies followed by Burrow, Kimball Young, Miller and Mayo. This led to an integration
of the psychiatrists and sociologists who were all along working independently.
The work carried out by these two professionals can be identified in three areas: the
first, relating to the social and cultural dimensions of mental illness, the second, to social
relations in therapy and the third, to prevention as a social policy in so far as mental-hygiene
practices are regarded, not as normative practices but as experiments for the testing of
68

theoretical hypotheses. Sociology of mental disorder uses a 'reference system' of four terms:
role, norm, value and communication, which formed the basis of various empirical studies.
Apart from the use of this reference system, general theories were also developed.
Leighton (1959) states that there is more mental disorder in disintegrated sectors of
society than- in integrated sectors, thus restating Comte.- But he was more precise by
proposing a dual index of phenomena defining social disintegration and by distinguishing
three processes of disintegration: on the technical level rapid changes in technology, on the
social level mobility and on the level of ideology or value-systems the conflict between these
systems (Leighton, 1959 cited in Bastide, 1972).
Sullivan and Parsons made significant contribution to the American Sociology of
mental disorder. According to Sullivan, the individual is not an isolated being equipped with
given instincts and drives, but as a social being to whom society continually presents
problems. He stressed that psychiatrists must study not individuals but interpersonal
situations. The most important thing for a psychiatrist is not the study of society as a whole,
its organization into classes or castes, but the study of formative relationships of the way in
which socialisation takes place in the formative years. Therapy will therefore consist in reestablishing
the severed communication and restructuring relationships. Another point he
stresses is that psychiatric observation is not a purely objective observation where the doctor
steps outside himself to describe a foreign being; it is like any other interactive situation, it
embraces both the patient's behaviour and the experience of the observer (Sullivan, 1937)
Parsons (1953), in his theory of' deviance', provided a framework for the study of
mental disorder. In the theory of deviance, he described that all behaviour deviating from
that prescribed by the society as opposed to conformist behaviour, which makes social life
possible. Parsons classifies phenomena of deviance along two axes. The first axis is
conformity-alienation, with at one extreme escape from the society and at the other over
conformist behaviour and rigidity in the application and norms. The second is passivityactivity,
with at one end insensitivity to social sanctions, which places the individual on the
margin of society and at the other end,- acts of open rebellion.
69

He is of the view that in mental disorder, there is divergence between the behaviour
of the individual and the expectations of others, between actual behaviour and social norms.
Although the psychiatrist studies individual cases of divergence, the conflict he is concerned
with is an internalised one. It comes from outside thus directing the psychiatrists back to
sociologist. The structure of personality is only a reflection of the social structure in the
individual (Parsons, 1953).
Parsons distinguishes three types of individual personality. 1. The personality
system is idiosyncratic in relation to the social system. 2. The individual is so engulfed by
society that his own personality is destroyed (compulsive, phobic, anxious states). 3. The
social system is disorganised and the sick person internalised this disorganization.
According to Parsons', the unifying and integrating forces in social systems are their 'valueorientations'.
Parsons observes that mental disorder is caused by the frustrations resulting
from role conflicts that lead to the individuals' alienation from the accepted norms (Parsons,
1953).
Merton (1975) observes that social structure exerts pressure upon the individuals
which engages them in different types of adaptation. He explains five types of adaptations,
viz., Conformity, Innovation, Ritualism, Retreatism and Rebellion, based on the acceptance
or rejection of cultural goals and institutional means. He classifies Psychotics as those who
adapt themselves to retreatism, i.e., rejection of cultural goals and institutional means.
Scheff (1966) observes mental illness as the reSidual deviance and he is of the view that
symptoms of mental illness persists when they are labelled by the society as mental illness.
With the emergence of Psychoanalysis, Sociology gained greater importance in this
field and the emergence of Social Psychiatry led to the recognition of the importance of
social factors related to mental health. According to Bastide in his historical review of
sociology of mental disorder, 'These theories are struggling with a double difficulty
represented by their extreme generality on the one hand and their specificity on the other.
They are too specific on the one hand in the sense they highlight only one factor, such as
70

disorganization, anomie, communication difficulties, conflicts of values or of roles. Parsons
is perhaps the only author who tried to take into account the multiplicity of factors by
reducing them to a series of miscellaneous examples. These different theories ultimately
tend towards a sociogenetic approach even if they are interested in the physical aspect of
illness' (Bastide, 1972).
Bastide (1972) also observes that they are excessively general and that they have not
differentiated between psychosis and neurosis. Speaking of social factors in mental disorder
in general does not mean very much. Thus, one must critically view these theories and
choose between a single factor interpretation or a multiplicity of factors, between a
sociogenetic or a structuralist approach.
71

Chapter Three
VOLUNTARY SECTOR IN MENTAL HEALTH CARE
In order to understand the mental health care system of our country, an attempt has
been made in this study to analyse the role of voluntary organizations in this field. The
estimates of World Health Organization reveal that at least 10 per cent of the Indian
population suffer from different kinds of Psychiatric Disorders (GO!, 1990). According to
the WHO Expert Committee Report on Mental Health Services in developing countries,
"The functional Psychoses occur ubiquitously, and serious mental disorder with an organic
basis occur more frequently than elsewhere. Non-psychotic mental illness forms a
significant part of the caseload in all curative health services. In addition, mental illness may
present itself under various guises such as physical complaints, criminal offences, suicide,
frequent or prolonged absenteeism from work, dropping out from school, etc .. " (WHO,
1975).
In the developing countries, the major functional psychoses, schizophrenia and
affective disorders constitute a large part of serious psychiatric disorders. Prevalent rates of
epilepsy are also higher in the developing countries rather than in the developed countries,
ranging from 0.9 to 2.1 per cent (WHO, 1974). It has been found that out of those suffering
from mental illness, over 60 per cent suffer from schizophrenia and bipolar disorders (manic-
: depressive) and 20 per cent from alcoholism. In a recent study, it has been projected that the
burden of mental illness is twice as much as the load from diabetes, Blood Pressure and
Cancer put together (NIMHANS, 1997).
The extent of other forms of mental disorders (psychoses, emotional disorders,
personality problems) is not defined accurately but there is no evidence to prove that such
disorders are significantly less common in developing countries than elsewhere.
In developing countries, though the population is predominantly rural, there are also
many rapidly growing cities. In the rural areas, the mentally ill are remote from psychiatric
72

facilities and their illnesses lead to a lot of problems, viz., loss of efficiency in farming, child
care and other important functions, leading to the increase in malnourished children and lack
of recovery of social efficiency by the patient. In urban areas the very process of
development produces problems of adjustment and adaptations which have important
implications for mental health.
In India, there are 61 mental hospitals, of which 34 are Government controlled, 22
are private sponsored by religious sects and one is an autonomous organization namely the
National Institute of Mental Health and Neuro Sciences. The following picture gives the
distribution of these hospitals in various states.
Table 3.1. Mental Hospitals in India
Total No. of Controlling Authority
State Psych. Govt. Private Vol. Bed strength
Hospitals
Kerala 20 3 14 3 1706
West Bengal 7 4 3 - 1555
Maharashtra 6 4 2 - 5755
Gujarat 6 4 1 I 658
Uttar Pradesh 3 3 - - 1557
Bihar 3 2 1 - 2483
Andhra Pradesh 2 2 - - 900
Karnataka 2 1 + I' - - 1260
Rajasthan 2 2 - - 365
Madhya Pradesh 2 2 - - 307
Jammu and Kash. I 1 - - 100
Delhi 1 1 - - 578
Tamilnadu 1 1 - - 800
Punjab 1 1 - - 811
Orissa I 1 - - 60
Nagaland 1 I - - 60
Assam 1 1 - - 1000
Goa 1 1 - - 272
TOTAL 61 35+1 21 4 20227
* Autonomous Orgaruzatlon: Nattonal Instttute of Mental Health and Neuro SCiences
(N1MHANS).
Source: Modified from Directory of Hospitals in India (1988) Central Bureau of Health
and Family welfare, Government of India, New Delhi.
73

Of the 61 hospitals, it is interesting to note that only nine hospitals are placed in rural
areas out of which eight are in Kerala and one in Gujarat. Apart from these hospitals, there
are about 33 hospitals in India, which offer further studies in Psychiatry, and 86 hospitals
have Psychiatric Units. This list excludes those units under the command of defence forces,
Railway, Public sector enterprises and many private nursing homes.
Not only are the psychiatric units and hospitals few in the context of the vast
population afflicted by mental morbidity but the proportion of psychiatric beds per 1,000
population is a mere 0.033, (GOl, 1990) which shows a deplorable state of mental health
service system.
The fact is that in spite of an increase in the number of hospitals from 17 in 1946 to
61 in 1980, the bed population ratio has remained the same. How do we expect to contribute
in any significant way to bring about "health for all by 2000 AD". In order to achieve the
goals of 'Health for all' by 2000 AD, it is necessary to seek the support of voluntary
organizations to supplement the Government services. The failure of the Government to
bring about a balance in the bed population ratio proves that work in this field cannot be
carried out exclusively by Government agencies. What India requires is a co-ordinated effort
of optimum utilisation of all available resources men, money and materials for the nation.
It is in this context that an attempt has been made by us to understand the role the
voluntary organizations can play in complementing the Government services to the mentallv
ill. Voluntary action originated as an alternative to the existing system. The inspiration to
voluntary action is attributable to many factors - altruistic motives, self-interest motives,
work-centred motives and other personal factors. The aspiration of our people during the
freedom struggle to build up a progressive nation led to various movements, which later got
converted, into voluntary agencies. The standing examples of early voluntary organizations
are Ramakrishna Mission and various church missionaries, which engaged themselves in
various voluntary actions.
74

The first mental hospital was built in Calcutta in 1787 and the last mental hospital
was built in 1966 in Delhi. Twenty-eight years have lapsed since then but no attempt has
been made to add more hospitals, in spite of the fact that psychiatric problems increased due
to increase in population and many other factors. Many states in India like Haryana, Sikkim,
Mizoram, Aruilli:chal Pradesh, Tripura, Manipur have no mental hospitals. Some hospitals
like Ranchi Manasika ArogyashaJa, Jaipur Hospital, Assam have to cater to the patients from
5 to 7 states (Chandrasekhar, 1991).
According to Sharma's report overcrowding, poor living conditions, lack of or poor
,killed manpower, inadequate treatment facilities and stigma have made mental hospitals
LIDpopular in the community (Sharma, 1992). The various epidemiological surveys
~onducted in different parts of our country show that for every 1,000 population at least 5
persons suffer from severe mental disorders (psychoses) like Schizophrenia, manicdepressive
psychosis, acute psychosis and organic brain syndromes. Twenty to thirty
persons (mainly children) suffer from minor mental retardation and its associated problems
like epilepsy, behavioural abnormalities. About 100 persons suffer from minor mental
disorders like anxiety, depression, hysteria and other forms of stress related syndromes
(Chandresekhar, 1991). The following table gives detailed information on the various
psychiatric surveys conducted in India.
75

• Ame J.iI nYCDlllfIC f1lel d .
I d
~uney~ In n III
Investigator Year Centre Population
Rate Per 1,000 Population
Urban
Rural Total Psychosis Neurosis Epilepsy Mentally
Retarded
I
Surya 1964 Pondicherry 2731 Urban 9.5 3.7 5 2.2 --
Sethi et.al., 1967 Lucknow 1733 Urban 72.7 4.0 24.2 -- 22.5
Ganguli 1968 Delhi 327 Urban 140 3.06 125.4 -- 9.17
Gopinath 1968 Bangalore 423 Rural 16.4 7 -- 2.36 4.72
Dube 1970 Agra 29468 Mixed 17.99 2.64 10.4 2.24 3.7
Elnagar et.al., 1971 Hoogly 1383 Rural 27 7.2 1.4 4.3 1.4
Sethi et.al., 1972 Lucknow 2691 Rural 39.4 1.1 5.2 2.2 25.3
Kapur 1973 Kota 1233 Rural 369 8.1 200 -- 5.7
K'taka
Verghese 1973 Veil ore 1887 Urban 66.5 5.7 47.6 -- 3.2
et.al.,
Sethi et. al., 1974 Lucknow 4481 Urban 67 10.3 27.1 3.6 10.5
76

Tabl~ 3.2 Psychiatric Field Survey. ID india ((;ontd)
Investigator Year Centre Population
Rate Per 1,000 Population
Urban
Rural Total Psychosis Neurosis Epilepsy Mentally
Retarded
Thacore 1975 Lucknow 2696 Urban 82 4 20 14
et.al.,
Nandhi et.al., 1980 West Bengal 647 Urban 207. I 34 165.3 6.2
1225 Rural 88.8 13.2 24.5 1.8
Shah et.a!., 1980 Ahmedabad 2712 Urban 47 16.3 21.4 I.8
Issac & 1980 Bangalore 1209 Rural 81.8 10.5 10.4 5.7
Kapur
Bhide 1982 Ootacamand 1658 Rural 184 17.2 147.1 9.1 2.4
Source: S. Sheshadri. Community Mental health News, Issue No: 2, 1986, cited from Mane and Gandevia (1993).
77

As can be seen from thl;; above table, there is a great variation in the prevalent rates
of mental illness ranging from 9.5 per thousand population (Surya, 1964) to 207.1 per
thousand population (Nandi et.al., 1980). All these studies pertain to different time periods,
locations and population size. Across the different types of mental illness, it can be observed
that the prevalent rates of neurosis has been found to be more than that of other types of
mental illnesses. But in all the types of mental illnesses, there is a variation in the prevalent
rates across various locations. The reason for the variation seems to be the difference in the
methodologies followed by different researchers (Seshadri, 1986).
Voluntary Activity in Mental health
The need for organised voluntary activity led to the formation of voluntary agencies,
registered under the Societies Registration Act and that are not expected to make any profit
on their activities and are considered non-governmental and non-political but still coming
within the purview of the rules and regulations formulated by the Government.
Since independence, the Government of India has stressed the importance of
community participation and the need for participation by the voluntary agencies in health
and development programmes. The voluntary sector tends to be responsive to meet the
pressing needs or perceived urgent needs of the community. The presence of voluntary
sector has so far been most strongly felt in the area of curative health services. Large
number of voluntary agencies have taken up various tasks of mental health care services, as
a result of the publicity and awareness created to bring about better health services to the
society and the national commitment to the Alma Ata declaration.
In the context of widespread misconceptions in the community about mental illness,
the immense potential of timely treatment and substantive evidence of the superiority of
mental health care in the community family setting vis-a-vis institutional setting, the
committed involvement of voluntary agencies can make a tremendous difference to the
success of the National Mental Health Planning (NMHP).
78

Voluntary organizations (VOs) have brought about novel approaches in the
implementation of the NMHP. One of the prominent voluntary agencies providing
comprehensive mental health services is the Schizophrenia Research Foundation (SCARF)
in Madras founded in 1983. SCARF and NIMHANS JOIntly conducted a seminar on
voluntary agencies and-mental health care in January 1988 in Madras. The seminar
highlighted the importance of the involvement of the voluntary organizations in bringing
about public awareness on mental health, evolving community based treatment and
rehabilitation programmes for the mentally ill and co-ordination of voluntary organizations
with government organizations in promoting mental health care (Govt. of India Report,
1990).
Voluntary Organizations (VOs) involved in mental health can be classified into two
broad groups:
1. VOs devoted primarily to mental health care.
2. VOs, which have general health/community development objectives and also offer
counselling and guidance services to the vulnerable sections of the community served.
The focus of the voluntary agencies working on mental health care on services for
the mentally retarded and after-care and rehabIlitation services for the mentally ill.
Some of the mental health services being attempted by a few agencies are:
1. Suicide prevention services: Offering emotional support to persons in crises, offering
24-hours crisis services; public awareness and support programmes.
2. Day care centres for the mentally ill, towards occupational therapy and socioeconomic
rehabilitation of treated patients.
3. Organising mental health awareness camps, training courses in counselling, and
voluntary work in mental health care for students, industrial workers, employed women
and others.
4. Half-way homes for the mentally ill.
5. Drug and alcohol de-addiction services.
79

6. For the care of the mentally retarded-special schools and hostels, training for special
teaching skills to mentally retarded and slow learners.
7. Behavioural counselling and guidance to high risk group children and youth from
broken homes, delinquent children, school dropouts, children of alcoholics etc.
8. Counselling and family guidance clinics to emotionally disturbed or socially deviant
children.
SCARF, in Madras, provides day-care services to Schizophrenia patients who are
discharged from hospitals, individual counselling for patients who can handle their problems,
group therapy, occupational therapy, vocational training, family counselling, social skills
training, dramatics to help patients to gain insight into their problems and overcome these
deficits, frnancial assistance to patients' children by way of school fees, academic assistance
to facilitate school children's education, recreational activities, etc.
Voluntary agencies such as Asha Niketan, Udavurn Karangal in Madras provide
monthly services towards preventing mental health problem, or promoting mental health to
vulnerable groups such as slum children, street children, school dropouts, unemployed,
adolescents, etc, through counselling and other assistance to these groups.
Throughout the history of mental health care, public opinion has played a greater role
than professional views. Notable contributions to the movement are by Ms Dorothea Lynde
Dix, a schoolteacher, who started a hospital, and Mr Clifford Beers, who introduced the
involvement of parents in the mental handicap care programmes. Due to various reasons,
it is less likely that mentally ill cannot themselves become a pressure group. Support and
guidance is vital in a number of ways. This can be seen by the role played by the National
Alliance for Mentally ill (NAM) in USA and Schizophrenia fellowship in England. They
have in the last decade, mobilised support for greater funding for research in mental
disorders and legal provisions for the mentally ill, in addition to other actions (Murthy,
I 992). In India, public and voluntary agencies have taken up activities in the following areas:
80

l. Mobilising public support and demand for services [(ex) SCARF, Madras; Sanjeevini,
New Delhi; Abhaya, Trivandrum].
2. Provision of' crises intervention help' [(ex). Sanjeevini, New Delhi; SNEHA, Madras;
MP A (Medico-Pastoral Association), Bangalore;;Sahaya, Hyderabad; Help, Bombay;
Helping hands; Crest, Vishwas, Tripti, 8angalore]. _.
3. Catalysing and supporting the families of the mentally ill and mentally retarded persons
[(ex) Samadhan, New Delhi; Shelter for mentally ill, AMEND, 8angalore; AASHA,
Madras].
4. Mobilising funds for research into mental disorders and their care. [(ex. SCARF, Madras;
Asha,8angalore].
Apart from these, Lions Club, Rotary Club, Charity Organizations have taken the
area of psychiatric morbidity for their intensive work. They have established half-way
homes and also periodically organise mental health care services. Thus, the newly unfolding
National Mental Health Programme hopes to be able to rely a great deal on the committed
involvement of the voluntary sector to tackle the problem of mental illness in the
community.
In the field of mental health care, there are about 37 organizations working
exclusively on mental health, and many more working in the areas of child and women,
family welfare, Rural Development, community Development, Health education and youth
welfare also have the mental health component in their work agenda. These latter
organizations do work in the areas of mental health but not to a significant extent as their
primary objectives are different.
Apart from these 38 organizations working exclusively on mental illness, there are
some more organizations working specifically on mental retardation. In order to fulfil the
objectives of our study which attempts to dwell into the areas of curative, preventive,
promotive, rehabilitative services, organizations dealing with mental retardation have been
kept out of the purview of our study.
81

elow.
The details of the thirty eight organizations working for the mentally ill are furnished
Table 3.3 Voluntary Organizations Working On Mental Illness In India
Place Name Services rendered
Madras SCARF Day care, rehab, custodial care
TTK
Excl. for drug and alcohol addicts
Sneha
Suicide prevention
Dr Bose Half way home (newly started)
AASHA Forum for the families of mentally ill
Asha
Day care, Counselling and residential care
YWCA For destitute women
Bangalore MPA Half way home
Asha
Half way home
Vikas
Halfway home
Chetana Day care Centre
Friends of Community based rehabilitation
NIMHANS
CADABAMS Custodial care
Nava Chetana Counselling and Day care
Atma Shakthi Halfway home
Vidyalaya
Pushkara Day care, residential and rehabilitation
CREST Family counselling
AMEND Association for the mentally ill
Prasanna Counselling
Vishwas Counselling
Helping hands Counselling for emotional distress
Dlpti
Counselling for marital discord
Apsara
Counselling
Family
fellowship
Society for Half way home
Psychosocial
Rehab. Service
Sanjivani Out patient clinic and rehabilitation
Abhaya Drug and alcohol addiction
Manasa Rehabilitation of Destitute women
Kerala Somana Half way home
82

Table 3.3. Voluntary organizations working on mental illness in India (Contd)
Place Name Services rendered
Dharwad Sowmansya Rehabilitation and research
Antara
Day care, counselling and residential centre
Samaritans Day care, counselling and residential centre
West Reach Day care counselling and residential centre
Bengal Pari- Day care counselling and residential centre
purnatha
Hyderabad Sahaya Suicide Prevention
Madurai Shristi Rehabilitation of the mentally ill
Trichy Sowmanasya Treatment for all psycho disorders
Delhi Sanjeevini Day care
Agra Manasik Shakti Counselling and after care
Kendra
Voluntarism- a Historical Perspective
Voluntarism is seen as typically oriented to the service of the victims of the state and
civil society, the principle goal being existential amelioration of victim groups. Its ideology
does not question why the victim groups become and remain so; its ideology if it may be so
called is based on the perception that every society would have victims who need to be cared
for (Baxi, 1986).
According to Baxi, 'Voluntarism is marked by its well bred horror of politics and
power, which are regarded as genuinely apolitical. Voluntarism is either revivalistic or
millenarian in its character. Concrete bonds of compassion and caring, fellowship of
suffering, hark back to communitarian ethos, stressing the good in self and society and
shunning the potential for evil avarice and domination in human beings. Creation of
community solidarity, not achievement of political emancipation is a hallmark of
voluntarism, At its best, it promises a millennium where we shall all recover our hwnanity
83

through the conununity which will marginalise the state' (Baxi, 1986). Baxi discusses about
voluntarism and activism thus. According to him, activism seeks to empower the victims.
It is based on some manifest or latent critique of the organization, of the distribution of
power in the society. The critique is based and finds its raw material in the pathology of
power. It unmasks the negative repressive power and is characterised by militant and radial
interrogation of power in the title of 'justice'. Activists are mostly in talking terms with state
power. They confront it, ambush it, overbear it when they can and also employ it if it serves
their ends (Baxi, 1986)
Voluntarism is seen as a phenomenon of capitalist society in which the public is
required to offer correction to vested interests, either prevalent in the Government or in
business. It is expected to give necessary correction, otTer experimentation, innovation and
research besides being its 'watchdog' (Nanavathy, 1996). In India, after independence,
Nehru's leadership provided a liberal policy of sponsoring the voluntary sector, especially
in the planning of developmental activities for social welfare. Many organizations sprang
up during this period.
Since independence, voluntary organizations have been recognised as servers of
humanity and honoured publicly with national awards. The required infra-structure for
offering financial aid to voluntary agencies was established to support voluntary efforts.
Initially, there was little difference between political leaders and voluntary workers. But
During the emergency period, a clear distinction was seen between them. Since often the
financial resources could only be mobilised by the social activists through permission of the
state rules and regulations, a new group of' Power brokers' have come into existence.
Roy describes the power brokers as selfish bureaucrats who make lot of forei!;,'Tl
money, take huge salaries on the pretext of helping the rural poor. According to him, these
voluntary organizations possess a lot of foreign funds and pretend to speak up for the rural
masses (Roy, 1986).
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Emergence of VOs
VOs emerged due to various reasons, either because of discontentment with
Government services or because of Government initiation and support. Some organizations
emerge due to local needs or in response to a natural calamity, some others due to an
established plan to promote large scale development efforts. They may also be the result of
a direct oftshOolOf organised efforts by locally recognised or unrecognised political or
religious elements.
NGOs have a crucial role to play in the development of any country. They take up
social work under challenging circumstances and develop innovative approaches to
problems. Educating the masses about their environment, often referred as
. conscientisation',- by Paulo Fraire, is generally accepted by the VOs as the basic aim. The
approach combines political education, social organization and grassroots development. It
helps the people to perceive their exploitation and to realise the opportunities they have for
overcoming such exploitations through mass organization. Conscientisation it is claimed
will also liberate the oppressors.
Their internal structure and linkages have given them the advantage of forming
global networks of citizen pressure. Clarke comments thus, 'Because of their size and
flexibility, they are able to experiment with new approaches to the crises and through
demonstration serve as pioneers or catalysts for government action. Because of their access
to media, they reach out to public and because of their non-interest in making profit they are
trusted by the public' (Clarke, 1990).
NGOs have frequently demonstrated their ability to help those in need especially
those missed out from the official aid prgrammes. They have been pioneers in new
approaches and keep challenging the development orthodoxy. Smallness among the NGOs
have always been advantageous to them in comparison to the giant programmes of the
Governments which are so often criticised. But sometimes small also means insignificant
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and therefore these NGOs aim at maximizing their impact and maximizing the value of the
lessons drawn from their experience without sacrificing the quality of their programmes.
Clarke observes that usually 'it is the governments that we the public love to hate;
NGOs can't be suspect. It is large bureaucracies we mistrust; small, voluntary organizations
are our friends. It is the- profit-motive that·we find vulgar; altruism is noble' (Clarke, 1990).
All Non-Governmental organizations (NGOs) undergo evolutionary cycles. Jeffery
refers to four stages which, according to him, all organizations pass through, viz., 1. start-up,
2. expansion 3. consolidation and 4. close-out. (Jeffery, 1992).
Organizational evolution is neither static nor unidirectional. Each organization has
its own stages of evolution. Some follow all these stages mechanically. Most of them are
found to follow less predictable course. Some do not follow all the stages and some reverse
the direction only to re-reverse later on. When start-ups fail, close-out takes place. Some
c1ose-out on one area of work and spin out new programmes and thus close-out and start-up
simultaneously.
Jeffery observes that start-ups may be of two kinds, one which is organic or self
generating in its origin and internally financed, at least initially, and those established with
external financing, conceptual and technical support. Internally financed NGOs are smaller
in size, pursue moderate goals related to the immediate needs and resource capacity of the
surrounding country.
An externally initiated NGO may build around locally perceived needs or may
promote an externally designed development approach. It may build on existing local
institutions and capacity or import a new organizational model. Some organizations are
more likely to be large, expand greatly and have broader goals (Jeffery, 1992).
The externally assisted organizations often undertake programmes pretested
elsewhere and ideally pilot test before they extend their organization. The approaches
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followed by these organizations differ. Some follow' welfare' approach wherein the NGO
provides all the services without any charges. Some others may opt for a 'contributory
approach' which requires material input and individual responsibility from the beneficiaries.
The purpose of this approach is to encourage local participation and community
involvement.
. Externally assisted organizations are characterised by formalised leadership,
administration and managerial approach than the unassisted grassroots organizations. Higher
level of institutional accountability is witnessed since external financial support will be
stopped otherwise.
Externally assisted NGOs have some advantages over the self-financed NGO. They
get outside technical assistance, field experience of the funding Organization, political and
economic leverage that the funding organization gives and above all they can take risks and
recover from past mistakes.
Organizational Expansion
Organizations expand due to various reasons either because of the increase in
beneficiary coverage, in the number of services provided, or enlargement of the current
project area. Planned expansion is an outcome of an increase in the available resources.
When the expansion is spontaneous it brings about financial crises as it is unplanned and
brings stress to the organization and its members as the expansion was unexpected.
Problems of accounting and monitoring also increase due to additional funding either from
the same donor or from different donors.
Successful expansion happens when the Organization has evolved constitutionally
to the point where it can manage the augmented level of activities effectively, and can
finance itself into the foreseeable future. Most organizations wish to retain necessary level
of programme autonomy from external actors, and provide desired and sustainable services
to their target beneficiaries (Jeffery, 1992). Roy comments, 'Expansion means complexity
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and complexity means decay. Regrettably this also applies to voluntary organizations!' (Roy,
1988).
Organizational consolidation is another process that some of the organizations
undergo. This occurs when the project taken up by the expanded section ofthe organization
is completed or when there is a financial crisis leading to retrenchment of staff and related
managerial problems. Planned consolidations are the result of systematic evaluation, timely
incorporation of lessons learnt and strengthening of administrative, monitoring and
evaluation capacity as required.
Internally induced consolidation depends on various factors, eg., -early recognition
of the problem, dynamic leadership, institutional will, willingness to make unpopular
decisions, access to necessary resources, luck, relative autonomy from donors. Externally
induced consolidation depends on:- financial security, external allies, well-established
Organization, committed membership, clear definition of programme niche, etc.
Organizational Close-outs
A close-out can be defined as either a full scale termination or a partial reduction of
project activities. An NGO closing out in one area may expand elsewhere; that net effect
may be an aggregate growth in the program size. In some areas the NGOs may replace one
particular activity with a new array of follow-up programmes of greater immediate
relevance.
Close-outs may be planned, either internally induced or externally induced. Some
close-outs occur in phases and diminish gradually. In some cases, close-outs are 'damage
contro\' devices to reduce the losses of badly designed projects or failed consolidation
attempts. Close-outs occur for various reasons, for instance, if the objectives are met and the
programmes successfully completed or in case if the projects is are unsuccessful and cannot
be retrieved. In some cases the beneficiaries have to be prepared to undertake the projects
on their own.
AA

Other reasons for close-outs could be faulty start-ups, foolhardy expansions, badly
managed or belated consolidations. Many organizations depend on charismatic leaders
whose disappearance might cause close-outs. Internal corruption, managerial incompetence,
a change in the political climate may also bring about such a situation. Dependence on
external technical assistance, pressures from donors;controversiai anti~authority stance of
the NGO in support of their beneficiaries may also sometimes bring about the downfall.
As the Organization weakens, its monitoring also weakens. The level of institutional
maturity of the organization determines whether the close-out is voluntary or involuntary,
complete or incomplete. Those undergoing involuntary close-outs are often associated with
administrative lapses. Their performance may at best be sporadic. Those who are fully and
voluntarily closing out do so in a formal and procedural manner (Jefferey, 1992).
Unintended close-outs have a detrimental effect on project beneficiaries. They may
produce significant financial losses, unmanageable debts or political disfavour which may
make ex-beneficiaries worry about future participation.
Strengths and weaknesses of NGOs
People' participation, - one of the main pre-requisites of sustainability is to secure
effective citizen's participation in decision-making. It is one of the main ingredients of any
non-governmental organizations' programmes. Beneficiaries participation has been
recognised as a major reason for the continuation of the programmes. Good programmes
tend to evolve holistic and integrated approaches.
Innovation has been another positive trait of the NGOs. The staff have greater
flexibility to attempt, experiment, and adapt new approaches. Flexibility is mainly due to
the smallness in size. Those involved in decision-making are few. Generally the local
officials do not participate in the NGO decision-making programmes. Since the scrutiny
from outside agencies is limited, the individual leaders are free to develop their own ideas.
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Sometimes the individuals may be led by untested approaches and the programmes may
then suffer from 'amateurism'. Since the investment - financial and of effort - are small, a
failure can also be a lesson learnt at lower cost.
Smallness of the NGOs helps them to formulate their programmes. Large
organizations face many complex problems. There may be omplexities arising from internal.
tensions due to personality, control over resources or just difficulties inherent in organising
the nitty gritties of functioning. Commitment of staff is another strength of the NGOs. The
staff of a good NGO, share common values and beliefs and are prepared to work for long
hours for low or even no pay. The staff imbibe commitment towards the organizations'
goals and dedicate themselves to its stability and growth.
Leadership is another important aspect that determines the strength of the
organization. There are two types ofleadership viz., charismatic which is characteristic of
people with a vision. They lead the organization by inspiration and personal qualities. Some
of them maintain an ill-defined structure, which tends to encourage dictatorial decisionmaking.
In such cases, organizations stagnate when the leaders are away. They are also
prone to decay and die when the leaders move on. These leaders cannot be easily replaced
and are likely to be so dogmatic in their approach that their adverse may bring about an
absence of a motivator (Tendler, 1987). In some kinds of organizations, the decision-making
becomes committee bound and staffs have no say in the matter. The committee members
who are usually the decision-makers are so distant from the staff that are involved in the
programmes that decisions may not address the problem properly or adequately. The
committee members are usually honorary members and receive no remuneration. Though
this is part of the voluntary ethose, it also distances the higher-level decision-making from
direct experience of the organization's work.
In some organizations, the leaders are committed to participation. They share the life
of the staff in the field even when it is not intensively done. They like decision-making to
be a collegial process within a tight management structure (Brown, 1988). In such systems
also problems can arise. The involvement of all the staff in decision-making may sometimes
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ecome very cumbersome for arriving at decisions. Under such circumstances, conflicts get
highlighted and give rise to factions among the staff. Different staff members perceive the
freedom to act and perception of their own role without reference to a strongly defined
overall mission. Thus, according to Brown, achieving the right balance between strong
leadership which ensures the resolute pursuit of strong ideas and openness of style which
ensures all staff feeling properly valued is the greatest management challenge for NGOs,
particularly as they grow in size. It is a problem that a few have cracked (Brown, 1988).
Many problems are also foreseen by the NGOs. Among the many problems are
learning disabilities and unclear concept of accountability. In the words ofBiswajit Sen, the
survival of NGOS has become delinked from their performance. He argues that close
relationship between articulate NGO leaders and funding agencies and the resource rich
environment in which NGOs work leads to an 'absence of pressures for performance for the
NGOS which makes self-evaluation of their own work a non-priority' (Sen, 1986).
One aspect of the NGO functioning that needs clarity confers around their
accountability. To whom are they accountable? Is it to the trustees, donors, staff,
government or the project partners. In some instances they may be seen variously
accountable to all of them. Yet in other instances, some NGOs may escape accountability
to all the elements. The "funding" individual can manipulate the small number of trustees.
The donors cannot monitor their NGO partners well enough because of their distance from
the field conditions. Staff is dependent on the leaders for their livelihood and unable to
challenge their decisions. The Government bureaucracy can be manipulated by powerful
political patrons. In the ultimate analysis, it is aware citizenry alone can 'control' the
leadership of corrupt and autocratic NGO leaders.
NGO salaries should be lower than average but when they fall too low the
professionalism slides. Clarke observes that the reduced salary should reflect the
'psychological pay' ,-the opportunity staff have of making a meaningful contribution
personally. According to him, 'It is the performance of the staff and the appropriateness of
their judgement for which the NGO must be accountable' (Clarke, 1988).
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Relationships between Government and NGOs
Friendly co-existence is present between the Govenunent and NGOs when the NGO
requires less from the Government to perform its functions, does not seek to influence wide
areas of development planning and where its tasks are not hampered by development
activities. Government agencies also feel happy when they feel neither threatened nor··
challenged and when the NGO tasks are not incompatible with its own objectives.
In contrast, if the NGO subscribes to a development theory different from that ofthe
Government, especially those NGOs that stress on people's participation, empowerment and
democracy, Government agencies recognise their economic value but they see these
elements as trouble-making. Tension tends to get generated between the two. NGOs can
afford to oppose, complement or reform the state but cannot ignore it. During the past, the
guiding asswnption was that development belonged to Government and Government alone.
NGOs have attempted to influence state policies and services to improve the efficiency and
equity of government services and to democratise state functions.
The five L's of scaling up strategies of the NGOs has been,­
Listening- listening to allies and critics.
Learning- improving research and evaluation
Linking- building networks and broad coalitions for effecting change
Leadership- fostering leadership among the poor
Lobbying- to influence those with access to much greater clout and resources (Korten,
1986).
Of all the problems, one of the most serious barriers to expanding the development
roles of the NGOs has been the difficulty that they face in working with one another.
Jealousies among them are very intense which break all collaborative efforts to work towards
common goal. Breakdown of the networks take place under such circwnstances. Ironically,
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at times it is felt that it is easier for the NGOs to work with the Government than among
themselves.
In spite of many odds against them, the NGOs have paved their way through many
development activities and have been successful in most of the areas, be it, educating the
masses, uplifting the down trodden, empowering women, eradication of social evils,
improving the health of the masses, creating social awareness on vanous problems, etc.
Indeed, they have been, they are and they will be a strong force in bringing about change and
development in the society.
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Chapter Four
THE THREE CASES
In order to understand the functioning of the organizations, an attempt has been
made in this chapter to identify the different components that make these organizations
The three organizations covered in the study are also assessed from the point of view of
their origin, objectives, size, staff, leadership, philosophy, services.
The three organizations selected as cases are: I) Medical Research Foundation, -
MRF 2. Manasa Rehabilitation Centre, -MRC and 3. Royal Medical Society, -RMS.
Origin of the Organizations
MRF, - Medical Research Foundation, was founded in Madras in 1983 by three
eminent psychiatrists. They started with a minimum amount of Rs. 3000/- by setting up a
small centre in Madras City. In the words of one of the founding members, "In the
beginning of MRF, whether Psychiatrist, Psychologist, or whatever, every person took
part in all the jobs starting from opening the office, cleaning, filing, counselling, etc. It
was like few people getting together to make a happy home." 'Mental Research
Foundation' is a consequence of the humble attempt made by a few to understand the
mystery of Schizophrenia and to help those affected by this complex problem.
MRC, - Manasa Rehabilitation Centre was started in 1973 in Bangalore. In the
beginning it operated from the premises of YMCA, Young Mens' Christian Association.
In 1975, MRC got its own building. The major donations to start with came from various
Christian Missionaries. The Organization grew by the combined efforts of the medical
personnel and Pastors with the objective of healing the physical body and shepherding
the soul to wholeness.
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RMS, - Royal Medical Society, began as a pilot project to house the mentally ill.
This was set up in a farmland made available by some philanthropists RMS is located in
the city of Ban galore in one of the calm residential areas. This is one of the 28 centres of
an International Society, whose other centres are in the different parts of the world. It is
the only one of its kind functioning in India apart from the newly started association for
the parents of the mentally ill at Bombay. The Bangalore house was to provide
residential care facilities for \0 male residents. To support this endeavour, the parent
organization, registered in London provided the services of a Co-ordinator to run the
house. Encouraged by the success of the home, two years later, in 1988, the RMS
headquarters secured financial assistance from the Overseas Development Administration
(ODA) and European Commission to make it into a model house of the residential areas
of the city with additional accommodation for II women.
This house was deliberately placed in a residential area, the aim being to provide
it in proximity to the larger community. The funding for the 'Model House' project
ended in the year 1991. From then on it has been sustaining on its own.
Objectives of the Organizations
The objectives of the MRF are the following:
1. Rehabilitation of patients suffering from schizophrenia
2. Undertaking research in the field of schizophrenia
3. Undertaking efforts to educate the public about schizophrenia to increase awareness
and reduce stigma.
MRC has the following objectives:
1. To serve the needs of the whole person by the collaboration of the medical, pastora
and other professionals on a non- profit and charitable basis.
2. To study and implement ways in which practitioners of the medical and pastoral
professions (Doctors, Nurses, Pastors, Psychologists, Teachers and Social
workers)
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may co-operate in helping mentally disturbed persons in need of their services.
3. To discover and understand more about psychosomatic problems.
4. To provide counselling for those who need it.
5. To give basic training to would be counsellors and workers of the Association.
The objectives of the RMS are as follows.
1. To offer help to those who are chronically mentally and emotionally disturbed and
need support to be rehabilitated and integrated with society.
2. To create public awareness and to enhance people's understanding of themselves
and the disabled.
3. To promote mental health in the community, particularly by providing courses in
personality development and humanism.
4. To collaborate with all the activities of similar organizations.
The organization proposes to achieve this by:
Providing
Training
Conducting
Organising
Starting
Promoting
Taking
Helping
Utilising
training to the staff in personal Development
others in the same area
courses in human relations and grollP_ work for interested persons
seminars/workshops/symposia for the (lublic
the therapeutic community movement
similar half-way homes at other centres
part in courses or related activities sponsored by others
families of the disturbed to restructure behaviour patterns as a move
towards healthier and more creative relationships
community resources and helping those disturbed lead constructive lives
with their own cultural milieu
Organization Structures:
MRF has been functioning for more than 17 years now. It has many centres,
namely, a) Day care centre located in the city of Madras; b) Residential centre for
women; and c) Residential centre for men; and d). two hostels, one for men and another
for women.
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MRF has its head office in the centre of the city of Madras The Day Care Centre
is in the same building. It is a two-storied rented house situated in one of the posh
localities of the city. It has a huge portico: in the portico, staff members conduct games,
like volleyball and badminton for the patients during the evenings. There is an annexe
with two small rooms-housingihe psychotherapy unit, which is used for psychotherapy
sessions. The ground floor has vocational training unit for the men. It has a printing unit,
a big hall, an extra room and a bathroom. The male patients occupy this floor. The first
floor consists of the Director's chamber and the staff rooms. It has two big halls, one for
the women patients to do their vocational jobs and the other where the staff give them
therapies and exercises. There is a small kitchen where they prepare snacks, tea and
juice. The second floor consists of the administration unit, library and computer rooms.
In addition to the day care centre (DCC), the organization runs two residential
centres (RC) in the outskirts of the city. At the time of our visit there was provision for
the placement of 55 patients. Forty-five of them were women and the rest were men.
There were some elderly men aged more than 60 years. The male residential centre was
being built with a capacity for 50 men patients. This centre was started in 1995. The
elderly male patients have now been shifted to the male RC. Apart from these, there are
two hostels one for men and another for women, whose inmates attend the day care
programme in the day care centre.
The hostels for men and women are situated near the DCC, in two separate houses
with separate rooms for each patient. Food is provided for the patients. The patients are
charged according to their economic status. The residential centres are situated in the
outskirts of the city.
These centres are built on a large open space. There are two main blocks. One is
a two storied building. It has the office, Kitchen, storeroom and a dining hall in the
ground floor. The occupational therapy unit and the stock room are in the second floor.
The other block houses the patients. There is a long corridor and the rooms are located
on either side of the corridor. There is no privacy for the patients as the rooms are
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separated from each other only by a wall. There are no doors for the rooms. They
resemble office cubicle. The rooms are very small just enough to fit a cot, cupboard,
table and a chair. There are a few independent cottages with all facilities for those
patients. This has a veranda, a hall, a bedroom, a kitchen and a bathroom. The patients
who can manage by themselves and are willing to pay the fairly high deposit required are
accommodated here.
MRC is situated in a very calm and peaceful area on the fringes of the Bangalore
City. It is housed in one of the ancient colonial Bungalows with a huge garden. There is
a lot of open space around the home. The residential quarters for the inmates are situated
in the middle. On one side is the administrative block which houses the staff room and
the therapy room. On the other side is an indoor auditorium, which is also used for
games, Yoga therapy and recreational activities. Adjacent to this is the hostel building
for those inmates who are either studying or working. Behind the main building, which
houses the inmates, there is a line of houses for the servants and the cooks. The main
building consists of the residents' rooms, occupational therapy room, classroom, dining
hall, kitchen, storeroom and accommodation for the house parents. The half-way home
has a capacity to take in 24 inmates with 3 inmates sharing one room. To take care of the
inmates, a couple work as house-parents who live in the same campus and create a homelike
atmosphere for the inmates.
Initially, RMS had two residential therapeutic community half-way homes. One
of the residential centres is located in the city along with the head office and the other in a
sub-urban residential area. This sub-urban centre is now under modification. Recently, it
has started a day care centre and a group home on the lines of long term rehabilitation.
The half-way home has a very serene and homely atmosphere. It looks like any
other beautiful house with a nice garden. It has many rooms with good light and
ventilation. The house has two floors and an outhouse. The inmates reside in the main
house, which is equipped with a huge hall, bedrooms, dining space and a kitchen. The
women inmates live in the ground floor and the men in the first floor. The house has lot
98

of space for moving around. The first floor has a large terrace where the inmates spend
their evenings. Some inmates also use this space for doing exercises. Both the floors
have a small annexe. The ground floor annexe accommodates the administrative office
and the first floor annexe is occupied by the house manager's family. The outhouse is
used by the staff members for storing medicines, conducting staff meetings and
counselling sessions for the individual patients and their families. On the whole, the
house is very cosy, comfortable and homely.
Another centre is situated about three kms. away from the above centre, in a very
calm sub-urban area that has a few houses and lot of greenery. The centre occupies two
separate buildings. One is for counselling and staff desks, has a large hall, a sitting room
for staff. The rooms are spacious. The other adjacent building houses the inmates. It has
a hall, two bedrooms filled with bunk beds, a kitchen and a dining space. The
architectural style of the house is that of of a typical home. The house is spacious and
has a big garden outside, which is used by the inmates to play games and for relaxation.
A social worker and a cook reside on the campus and volunteers keep visiting to organise
activities for the inmates. This Centre is also being modified at present.
The unit of the Royal Medical Society was started two years back exclusively for
the parents of the mentally ill. Another unit was established in Tumkur near Bangalore,
in association with a charitable trust. Another half-way home for the rehabilitation of the
Alcoholics and Drug Addicts has been registered. RMS has also set up a Group home
Facility at the request of many families. This institution can accommodate about 12
residents. The facility is taken care by one of the volunteers who was trained by the
organization as a therapeutic community worker. She had been working at the half-way
home for more than five years before she took the responsibility for running the group
home. The group home facility is near the half-way home. It is situated in a big house
built specially for this purpose. The caretaker is given free food and accommodation to
take care of the patients. Many of the patients go out for jobs. Most of them are
independent and take care of themselves. This is a long stay home for Schizophrenic
99

patients. Those who seek admission to this home are expected to pay a deposit of around
5 lakhs, a part of which is returned when the patient wishes to leave the home.
One of the latest institutional facilities added by the organization IS a centre
offering day care and vocational training for the mentally ill. This is situated in one of
the busy residential areas of the city. Though it is located in a crowded area, the centre
itself has been built on a piece of land more than one acre. This centre was inaugurated
in 1997 and started functioning from January 1998. Its built-in area consists of two
storied building with a basement having a huge auditorium, which is used for functions
and for playing games. The first floot consists of the reception, office, vocational
training, dining and wash rooms. The staff members have been provided with office
cabins. The centre has recently started a postgraduate course in Psycho-social
Rehabilitation (August, 1999). The second floor occupies the classrooms for the
students and dining rooms for students and faculty.
Organization Leadership
All the three organizations are headed by psychiatrists. Whether they are present
In the organization or not, all the events of the organization are reported to the
psychiatrists now and then. At MRF, a psychiatrist who is one of the founder members is
the Director and Co-ordinator. She is a very experienced psychiatrist retired from the
Government mental hospital. She is a charismatic leader and the staff are faithful and
loyal to her. Because of her sincere efforts towards care and rehabilitation of the
mentally ill, she has gained the respect of everyone. Her efficient leadership has resulted
in a good team of staff working towards the goals of the organization. However, the
future expansion of the organization is perceived by one of the members as being
problematic since the second line of leadership has not yet emerged. According to him,
the most crucial element in a big organization is the quality of leadership at all levels.
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When the organization is small, decision-making is informal and spontaneous.
But when the organization grows big, its leadership has to be formalised. Sometimes the
culture of the smaller organization persists which tends to burden the top and delays the
emergence of leadership at lower levels.. The delay in transfer of leadership leads to a
lag in the activities. In small organizations, a second line of leadership can be trained at
lower risk to the leader. Bigger organizations would also function better if it is conceived
as a combination of modules of smaller unit with largely self-sufficient and autonomous
leadership all don the line. Inter-personal relationships in such modules are healthy and
there is greater b'TOUP dynamics among the members of the organization. When an
organization grows big, there is heterogeneity and the staff are specialised in their own
activities. Small organizations have better group dynamics. Their teamwork is healthy
as the members share responsibilities. Leadership in smaller organizations can be
equalitarian in nature and not authoritarian. Our informant perceived that when the top
charismatic leader goes, there could be some problems in the organization in terms of cooperation
among the staff. He feels that the new leader may not be as efficient as the
present one. However, the staff at MRF feel that good teamwork would continue in spite
of change in leadership.
One of the founding members commented that when MRF was small, it had all
the advantages of being small. As it is growing bigger it is experiencing the pains of
growing big. He remarked, 'Small is beautiful. Rather small was beautiful. Though, of
course, one cannot deny the successful growth of the organization'.
At MRC, a psychiatrist of the Government hospital heads the organization.
However, he is not present in the organization throughout. A Psychiatric social worker
supervises the functioning of the organization. In this organization, there is no second
line of leadership as the other staff members are very young and they keep changing
often. The leadership in this organization is not so charismatic or effective compared to
that of MRF. Leadership is unable to enthuse the staff and supervision tends to be lax.
Unlike MRF, there is a feeling that the staff do not function as a team.
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At RMS, the leadership is similar to that of the MRC as the day to day
supervision rests with a Psychiatric Social worker and the psychiatrists are not always
present in the organization. Even though there has been much turnover of staff at RMS,
there is always a second person to take over the responsibilities of the leader during
hislher absence. The staff members are trained to take up responsibilities and change over
of leadership occurs smoothly resulting at efficient teamwork. This is not the case with
that of MRC. Most of the days the organization is run by the lower level staff without
much monitoring
At MRF, one can find a very powerful and effective leadership binding the staff
together. Whereas at MRC, in spite of the organization being small, the leadership is not
so strong, and the stafflack the drive to work efficiently because of weak monitoring. At
RMS, the staff are trained to take up responsibilities and change over of leadership occurs
smoothly resulting in efficient teamwork. Thus, the organization requires an efficient
leadership and a trained staff who can takeover responsibilities in the absence of the
leader
Organization staff
The staff at MRF are highly professional and have learnt a lot through experience.
The quality of service provided is also very good. Staff are predominantly women. Male
staff tend to leave due to the following reasons, - insufficient job security, lower
remuneration than in other commercial and governmental organization. Successful and
career minded workers opting for more remuneration hardly stay in the organization.
They opt for better avenues of job where pay packets are higher.
One of the members of the organization commented, 'commitment can get
exhausted if the remunerations are inadequate. More efficient staff can also get lured
away by high salary offers. Some may get enslaved by the organization, since they do
not have inclination to risk change of jobs. Some get dejected by low pay and do not
believe in the cause anymore, resulting in lacklustre performance. Those who are young
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keep looking for better options and gradually do not stay in the organization for long.
Those who have the inner drive to do work committedly stick on to the organization'
(April, 1994).
To avoid the problem of staff turnover, a member suggested that, the salary
structure should be changed. But this is a Herculean task according to one of the decision
makers of the organization, since the organization provides free service to patients and
receives no payments. It, therefore, cannot pay salaries on the same basis as the
organised sector. The remuneration of the staff depends on the availability of funds.
Acquiring funds has always been a difficult problem for the organization.
The Day Care Centre (DCC) of MRF has 15 professional staff including five
Psychiatrists, two Social workers, two Psychologists, six administrative staff, 12
supporting staff which includes two instructors, one public education officer, one
statistical assistant, two cooks, three drivers, two watchmen and one maid.
Each one of the residential centres is staffed with an occupational therapist, a
social worker, superintendent, cooks and servants who live on the campus. Apart from
this, the IDRC project staff at the rural centre consists of three social workers.
MRC has, in its team, four psychiatrists who work for NIMHANS. These
psychiatrists are not always present in the organization but the patients go and visit them
in the hospitals for consultation and review. They have a counsellor, who is a
psychologist and three social workers out of whom two live in the campus, one in charge
of the hostel and the other in charge of the half-way home. A couple stays in the
organization campus to take care of the residents and running of the organization. They
are called the house parents and they are trained counsellors who can take care of the
problems of the residents. They create a homely atmosphere for the statIo
The administrative staff consists of an administrative officer, an accountant, a
clerk and a secretary. Apart from these, there are about 15 volunteers, mostly women
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who organise various programmes for the inmates. Strikingly, one of their staff is also a
patient of the organization and has been offered job as a rehabilitation placement.
The office is managed by an Administrative Officer, retired from the Ministry of
Commerce, Government of India. His responsibilities are taking care of the overall
supervision of the organization and in charge of correspondence and most of all fund
ralSlng.
At RMS, great importance is gIVen to recruitment and training of the staff.
According to one of the senior members, "Staff being the crucial ingredient by which the
therapeutic community stands or falls, a staff member of the Therapeutic Community
house has to be a jack of all trades. The staff member is somebody who can be
therapeutic not only in his personality and his professional discipline but also in his daily
living. Hence, the staff of RMS are trained to deal with multifaceted problems".
Each staff member is assigned to at least 3-4 residents. Their role is to encourage
positive interaction between them, to give support to the residents and to carry out the
duties and responsibilities towards the welfare of the whole household. They keep in
touch with the residents' families and the Psychiatrist as and when necessary. The staff is
also responsible for the day to day administration of the home. The staff come with a
background qualification of Clinical Psychology or Psychiatric Social Work and also
receive training under the training programme of the Fellowship.
The organization staff consists of Psychologists and Social workers. There is a
predominance of social workers among the staff. Though there is no psychiatrist
available in the organization round the clock, the staff take the patients to their respective
Psychiatrists in the hospitals whenever there is a need. The house manager is a social
worker. She is very well qualified and has undergone lot of training in counselling and in
the philosophy of the organization. She heads the clinical staff, and is assisted by a
sociologist, trained in rehabilitation, psychotherapy and counselling. He has wide
experience of working with the mentally ill and problem children. He has worked in the
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area of rural rehabilitation, administration and special education. His major jobs are to
supervise and conduct various programmes, therapies for patients and families,
management of clinical records, maintenance and documentation of records, supervision
of staff, allocation of duties to staff members and co-ordinating their activities.
According to him, the i"equirements of staff working-ina-therapeutic community
are as follows: a) willingness to work; b) minimum insight and perception; c) personal
commitment; and d) service to others. Other therapeutic staff are a Psychologist and
three social workers, of whom one resides in the home. These staff are responsible for
the day to day running of the home and are guided by the house managers. The
administration section consists of an Officer and a Secretary who take care of all the
administrative work. The other helping staff members are a cook, a helper and a servant.
All are well acquainted with the activities of the organization and are very much involved
in creating a congenial atmosphere for the patients.
The staff teams in the three organizations differ a great deal, though basically they
have similar qualifications. At one end there is the professional team of experts at MRF,
but the atmosphere there is very formal. At MRC, generalists predominate and
atmosphere is informal. They work under the guidance of experts. At RMS there is a
good balance of professionalism and at the same time an infom1al community set up.
Services and Functions
MRF has its head office in the centre of the City, which caters to Day care
service, Counselling and Occupational therapy for the patients. All these services are
offered free of charge. Day care services are offered from 9:30 AM to 4:30 PM. on all
working days. Individual counselling, group therapy, vocational counselling and job
placement are the other services provided. Most of the patients fall in the age group
between 18-75 years.
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The following table illustrates community projects of MRF
Table 4.1. Community projects of MRF
Project MRFOXFAM MRF IDRC
(Rural)
Period 1987 onwards 1988 onwards
Service Area 88 villages . 202 villages
Outpatient Monthly Fortnightly
Clinic
Training group Health workers Mental Health workers
and Volunteers
Community Film shows, talks, Film shows, talks,
awareness pamphlets villupattu,(F olk sonf!)
Rehabilitation Home based Job placement, tapping
programme, financial sources for
fami ly interaction loan, starting small busireferral
to other ness like sauce shop,
centres
agricultural activities,
etc.
Subject Identification of Identification of mentally
mentally ill
ill,
Survey of area,
Rehabilitation,
Domiciliary delivery of
medicine
IDRC - InternatIOnal Development Research Centre
Oxfarn - a funding agency (England)
Source: MRF Report, 1994.
MRF Slum Project
1992 onwards
5 slums
Weekly
Health Aids from the
local VO working on
health
film shows talks
Assistance to agencies
undertaking rehabilitation
like centres for
mentally retarded,
addiction etc.
Identification of mentally
ill,
survey of the area
The organization offers rural services in one of the Taluks of the state. The staff
visit the place once a month and also train health workers and volunteers who stay on the
Job throughout the month. Similar service is offered in another rural area near the city
once in a fortnightly basis. In collaboration with another voluntary organization, it holds
weekly mental health clinic in five slums in the city.
A tearn of four professionals viz., two psychiatrists, one psychologist and one
social worker visit the rural centre in the taluk every first Saturday of the month. A team
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of one psychiatrist and two social workers visit the rural centre near the city fortnightly.
MRF runs a project funded by the International Development Research Centre, IDRC, on
"Community-Based Rehabilitation". This project has an office staffed with three social
workers and trained health workers selected from the local village people. Another team
composed of one psychiatrist and one public education officer visit the slums in the city
weekly. The following table gives the approximate figures of the beneficiaries as told by
one of the senior psychiatrists ofMRF.
Place
Number
Patients seen at MRF out-patient Department 3,500
Patients registered in the vocational training centre 750
Children receiving support from the Childrens' fund 300
No. of patients seen in community services at
a) taluk 2300
b) rural centre near the city 500
C)slum 75
No. of patients at the residential centre 150
The programmes and activities of the organizations can be classified as
1) Research activities;
2) Clinical services; and
3) Educational services
The psychiatrists in the organization are involved in vigorous research. The
organization has been recognised by NN1HP (National Mental Health Programme). The
research undertaken by it is recommended and recognised by the NN1HP. Its services
have been found to serve as a model for replication at the national level. Many
researches have been conducted by its team of psychiatrists in collaboration with WHO
and ICMR. There are many ongoing research projects, apart from the various symposia
and seminars that are organised at the national and international levels. Some of the
projects ofMRF are, -'Dementia', 'Quality of life' in colIaboration with the Government
Psychiatric department and 'subjective well-being', in collaboration with the WHO.
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As part of clinical services, MRF offers services at various levels, identification of
illness, counselling, treatment and rehabilitation. The selection of the patients is
restricted only to schizophrenia. Every patient who enters the organization is first
screened by the psychiatrist who identifies the illness and later the patient is allotted to a
team of one psychiatrist, one social worker and one psychologist. The social workers
perfonn the jobs of tracing the illness of the patients, history of illness, onset of
symptoms, and establish a thorough case history of the patient. The psychologists
examine the cognitive skills and social skills of the patient and also undertake behaviour
analysis. Once the details about the patients are established, the team has meetings with
the patient and the family members to draw a plan of action for hislher treatment. This is
followed by further weekly meetings with the patients and the team, as well as individual
sessions with each expert. During the day, the patients are engaged in occupational
activities such as candle making, agarbathi making, screen printing for men and various
handicraft works for women, like bag making, embroidery, etc. In the residential centres,
two psychiatrists and one psychologist are available for consultation. These experts
usually come from the DCC. The day-to-day functioning and management of the
Residential centres is under the care of social workers.
As part of public education service, MRF organises video shows, and meetings in
schools, colleges, slums and villages. The organization has brought out a video cassette
which is frequently telecast by the state and the national television network. Frequent
talks on mental illness prepared by the organization are relayed on the All India Radio.
Poster painting competitions on mental illness are organised every year during the mental
health week. Pamphlets in both English and Tamil are circulated widely. An attempt is
made to update them frequently. MRF has, among its staff, a public education officer, a
sociologist who is entrusted solely with the responsibility of preparing education
materials and various educational programmes
Initially, MRC began with the objectives of counselling and awareness generation
regarding mental illness. The first programme which caught the attention of the public
mainly focused on suicide prevention programmes. Under this programme, the
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organization trained about 63 volunteers in suicide prevention enabling them to give
counselling to those who had attempted suicide. These volunteers visited hospitals in the
City and talked to the concerned persons. They conducted a survey on this population.
In this manner they could cover 159 persons, of which 112 records were completed and
47 uncompleted. The data collected revealed that out of the 112 cases, most of them
were men (76). The age group of these patients were mostly in the 15-25 years age group
(79) and the next highest number was in the more than 25 years age group and the least
among them were less than 15 years of age. Most of them were married (78) in number.
The reasons for attempting suicide among the below 14 group were a) failure in the
examination; and b) rejection and frustration. Among the adults, marital disharmony,
frustration and fear were the main reasons for attempting suicide. Most of them took an
overdose of sleeping pills or poison. A follow-up study was conducted by MRC with the
help of volunteers. The organization planned to put up a play titled 'I want to live'. It
took efforts in giving regular counselling to those prone to suicide. The significant
achievement made during the first year of establishment was that nine potential suicide
cases contacted the organIzation for help due to the publicity given to the programme.
Though MRC did much in the field of "suicide prevention", at the moment not
much is done in this area, except attending to the help-line calls from suicidal and
depressed cases. Many who are depressed call up the organization and receive immediate
suggestions to improve their mental status.
In the initial days, study meetings had been held for the counsellors on 'Human
encounter' and· Care of the sufferer from depression of spirit'. Another programme was
implemented for an Institution of unwed mothers for three months. It was basically a
counselling session for the unwed mothers. About twenty girls received counselling from
the staff members trained in counselling.. The girls sought help from the staff for the
following:
I. To help them have confidence in themselves and be trusted and loved as before.
2. To help them have courage to face the world either with or without the child.
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3. To help them not to live a 'masked life'.
4. To help them to be accepted by their family and society.
One of the staff members reported, 'There was overall improvement in those who
took counselling. Apart from the destitute, about 20 individuals also sought help and
were given individual counselling. A majority of them showed total recovery and others
showed improvement'. The organization also conducted training programme for priests
and nuns on Marriage Counselling. As part of rehabilitation programme 16 alcoholics
were admitted in the AIMH (presently NIMHANS) and out of those 6 were placed in
jobs. Only one of them did well in the job, two did not take up the job and others left the
job.
Generation of awareness on mental health was taken up through "training" and
communication media projects. As part of public education, the organization conducted
symposia on 'Marriage and Suicide Prevention' and also made films on mental illness
which were shown to the public. The films had very interesting themes. One of them
was about the city and its growth and the problems arising with specific focus on mental
health. The film was titled, 'Are the City and its Structures Planned to SatisfY Human
Needs?' The film illustrated the problems faced in crowded cities and ended with the
hope that a truly human city would arise out of the cold structure of stone. Another film
had for its title, 'Between the Man in the Crowd and the Solitary Man, is there Anything
in Common?' These films were shown to the masses to make them realise the importance
of mental health and the problems of the mentally ill. Training courses in counselling
were conducted for different groups of people, School Teachers, Nurses, Policemen,
Priests and Nuns.
During the seventies there was further progress in the direction of "service". A
half-way home planned in the first year of the 70s was realised only in 1975. During the
year 1974, the organization made an assessment of the previous year's achievements.
According to the same, it was felt that the work carried out so far had been in harmony
with the objectives set out. However, service to non-English speakers and children below
110

12 years needed to be stressed. The organization also had, as one of its objectives,
increase in its membership.
The year 1975 was a great mark for the organization for it was during that year
the organization got its own building. In the words of one of the staff members, the
Association 'has come on its own, building came up on the land granted by the Kamataka
Government with co-operation from the Municipal Corporation Office. The phase of
. community involvement' started with the creation of a half-way home to rehabilitate the
mentally ill'.
During this year, the organization collaborated with other organizations such as
YMCA to start a Counselling Centre and the Association of Social and Moral Hygiene
and Karnataka State Productivity Council in conducting programmes to sensitise the
public. It also associated with the Victoria Hospital and NIMHANS in organising study
groups and programmes on suicide prevention. It became a Centre for training the
students qualirying for Master's in Social Work in Suicide Prevention work and practical
ways to make a study of the problem of suicide in Bangalore. The United Theological
College requested the organization to give practical training for the students of Theology
and Counselling on exposure to the problem of the wider society and problem solving
with an inter-disciplinary approach. The organization also trained the staff of the Police
Department on rehabilitation for those who attempted suicide.
The various programmes carried out by the Organization can be summarised as
follows:
Programmes to sensitise Public
- Organising public symposia
- Relaying educational programmes on mental illness on All India Radio
- Organising dramas in various places ofthe city
- Publishing pamphlets and news-paper articles on mental illness.
Training Programmes
- Training on suicide prevention
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- Training of counsellors on various aspects
- Practical training on counselling to various groups.
Services Rendered
- To those who attempt suicide
- Half-way home
- Counselling centre in association with YMCA
In 1975, MRC organised symposia on various themes, viz., 1. Prostitution, 2.
Alcoholism, 3. Prevention of Suicide and 4. Play on . I want to live'. The training
programmes during the year included programmes for volunteers on prevention of
suicide, nurses from the Government Victoria Hospital and students of the Bangalore
University. The beneficiaries of the services included alcoholics and those who
attempted suicide, admitted in two Government Hospitals. Twelve people from the
Alcoholic Anonymous were helped by way of counselling during the year 1975. The
staff of the organization once in every week viSited the suiCide cases admitted in the
hospital and follow up was done in the YMCA counselling centre. Some of those were
encouraged to start small enterprises and bank loans were provided for the same. During
this year, MRC organised itself into various committees to manage different activities of
the organization. These committees are namely, -
I. Managing committee
2. Suicide Prevention Advisory committee
3. Half-way home sub-committee
4. Suicide Prevention Volunteers committee
5. Counselling committee
6. Public Relations and Education sub committee
7. Building sub-committee
8. Admissions committee
9. Alcohol Education sub-committee
10. Local Fund Raising committee
11. Staff committee.
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These committees take care of their respective responsibilities and thus share the
overall functions of the organization. Each committee consists of the members of the
organization, life members and the individual members, the staff of the organization and
the volunteers of the organization.
The special activity of the organization dlJrj ng the year 1980 has heen the Teachy
Project which was funded by Oxfam to prepare educational kits for children and mentally
retarded children. in particular. In the year 1981, one more Counselling Centre was
started in one of the areas in the city. The membership of the organization steadily
increased with ordinary members increasing to 78, life members increasing to 46. In the
year 1982, a new turn took place in the Organization as women volunteers joined the
association for the first time and the ordinary membership of the Organization rose to 100
and life members increased to 51. In 1983, the two Counselling Centres one in a
residential area in the city and the other at YMCA were closed due to lack of funds and
dedicated staff.
After five years, i.e., in 1987, the organization saw an increase in activities and
an increase in membership, which totalled to 104. The activities of the organization
included Counselling Training, Navajeevan hostel for those rehabilitated patients holding
jobs, regular meetings of the parents or the guardians of the patients every month,
improved occupational therapy programmes, preparing work manual for the staff. The
organization also conducted a review study on the admissions and discharges of the first
100 residents of the half-way home under the headship of one of the leading Psychiatrists
in the city who is also a member of the organization. A workshop on transactional
analysis was also held to re-orient the staff on the philosophy of the organization. Two
more committees were added to the already existing 11 committees of the organization,
viz., - half-way home Committee and Work Rehabilitation Committee.
Services of the half-way home at MRC focus on the responsibility of the
community towards the care of the individual once he returns to the society from the care
of the professionals in the mental health field. One of the members of the organization
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commented, "The society and the family and the community should awaken to the fact
that in their race for material gains, they have forgotten their obligations to the
individuals who is lonely, lost, sick and deeply hurt. The individual when he returns after
treatment will view them with suspicion. He may ruminate thus;
"If you stop. in the street and look at me,
If you give me your hand and take it,
AIld if you then desert me,
Do not be surprised
When another comes to give me his hand
If I hit him in the face"
One of the parents of the residents while appreciating the role played by MRC in
dealing with the residents, commented, 'some people have to see and touch love to know
if it is there; others have a blind understanding of it'. The patients who are affected by
mental illness have to be often told that they are being loved and the organization has
been successfully imparting service, care and attention to the residents.
In the first year of starting the half-way home, 24 persons were given admission,
out of which 12 were alcohol addicts, 4 were drug addicts and 8 were suicide-prone.
When the half-way home was first started one of the members of the Organization
described thus; 'Half-way home is an artificial community where one can help an
individual to remain a social being by taking more responsibility for himself and helping
others share his feelings keeping in communication all the time. The tasks of the
community is to be a therapeutic community, meaning that when mental illness cuts-off
an individual from his natural place in the community, the community itself can be a
therapist in helping him find his own place back in the community'.
After seven years of starting the half-way home a hostel was started for those
patients who had reached a stage of taking up studies or work but still had not reached the
stage of getting back home. AIld for those patients who were not accepted back home by
the family. In the words of the house parents, " the individuals who come to us for care
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and treatment are but pausing on a long and tiresome journey homeward ... Do we after
having cherished and loved these individuals return them to society to be salvaged,
ravaged and rendered insane again?" The starting up of the hostel was thus to extend
care to the recovering persons so as to help them to help themselves.
With the completion of the hostel building and quarteft> for the staff, viz .., house
parents, cooks and gardener and an auditorium, Jv1RC attained the basic infra-structural
facilities. The organization has a vast open space with lot of greenery and garden and the
most striking feature of the organization is the discipline and cleanliness that is
maintained.
The hostel is meant for some of the patients who go out for jobs or for some
educational course. They stay in the hostel rooms during the nights and have food in the
mess of the half-way home. According to Sameer, the social worker who takes care of
the patients in the hostel, the patients have to be constantly supervised for cleanliness and
maintenance of their rooms and personal cleanliness. They try to avoid him many times
as they know that he would make them work. But, according to him, those staying at the
hostel are much aware of their responsibilities and can manage by themselves. They
have been residents of the half-way home in the past and are taught to take care of
themselves. During the time of the field visit about nine patients were staying in the
hostel and all of them were young boys.
The style of functioning in the two houses of RMS is basically informal although
its day to day life is organised by a structured programme. Therapeutic community
principles are followed in this programme. This reflects the ordinary pattern of a
household. Rehabilitative activities form the core programmes. Regular habits are
inculcated by setting times for getting up, personal care, meals and other activities
because many residents have been incapacitated so far as normal routines are concerned.
Throughout the week, the morning sessions have many work activities. Occupational
therapy activities are set to individual needs, which help residents develop a number of
skills and the habit of work. Throughout, the emphasis is on group life. Residents also
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have individual counselling sessions with the staff. Families are involved from the very
inception of placing their wards in the rehabilitation process, in the family therapy
sessions and in the three monthly progress review meetings. Referrals to these homes are
made by psychiatrists. The family and the applicant are invited to stay for a trial period
ranging from 3-7 days. This gives him or her a chance to experience what the house is
like and then to make the decision to live in the community. Since the establishment of
the society, more than 300 residents have received rehabilitation programme and are
drawn from all over the country and even from neighbouring countries.
To prevent the staff from undergoing burnout due to work stress and pressure,
they organise retreat camps that cool their minds and make them introspect and build up
more energy to deal with crisis situations.
Such retreat camps are organised on holidays in a farmhouse belonging to one of
the staff. On that day the volunteers take care of the patients. It is a day that staff
members wait as it gives them a great break. This break of routine is very much required
to avoid monotony and frustration of following the same routine. This is very important
for mental workers who undergo much fatigue.
While giving counselling or treatment to the patients, it is very important to be in
a good frame of mind or else they may not be able to convey what they want to and the
patients too would not respect them and care for their advice. During the retreat day, all
the staff members relax from their everyday routine. They discuss the problems faced by
them in their work in the organization. They discuss each patient's case, their progress,
problems and the future plans for the patient. Many of these discussions are not possible
in the organization, as they demand privacy and uninterrupted thinking without any
disturbance. Each staff member, therefore, also explains the individual cases that are
being dealt by him or her to a senior staff member. Discussions within the group meeting
of the staff do help them in sharing the problems faced by them and also to get a feedback
from the other staff members. These exercises help them to learn through their mistakes.
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Each one makes a critical assessment of oneself and the others, which helps them in
improving their understanding.
Training Programmes
The parent society of RMS placed a Training Officer for a period of two years to
start a training programme at Bangalore. In 1989, an In-service Training programme was
organised by the RMS for the staff. This was a ten months course with two hours session
twice a week. Based on this experience, The RMS India, modified the duration of this
course of ten months to four months duration. After running the training programme of
four months duration, the Fellowship organised a National Workshop in the year 1992 on
'Rehabilitation of the Chronically Mentally Ill-Training and Research Needs'. The
fellowship received support from the European Commission for this purpose and also
from the Department of Science and Technology and the Indian Council of Medical
Research. Based on the recommendations arrived at this workshop, the duration of the
training programme was revised to six months and at present training programmes are
held once in six months. From 1989-95, the RMS has trained about 39 paraprofessionals.
The trainees have come from different parts of India. The organization
has made a video on the approach to therapeutic community with suitable modifications
to suit the Indian lifestyle, social and cultural milieu. This has been shown in different
forums to get feedback on the same.
As part of the activities of the organization, training programmes are conducted
for various professional groups and students. These training programmes are organised
by the staff of RMS organization and this is only one of its kind in India with an
emphasis on therapeutic community approach. These programmes cover the following
aspects during the course.
1. Therapeutic community management
2. Residential management
3. Experiential group work
4. Creative group work
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5. Counselling in the therapeutic community
6. Mental health and mental illness, - current concepts and practices.
The organization also offers placement servIces for students from different
universities and Departments and provides orientation courses to them. Apart from
training the outsiders, the organization also gives training to the staff of the organization
on the functioning of the organization and orients them in the management of the home
and its various activities. Training programme for the newly inducted staff is also
organised. This training takes place in a span of 25 days. They are trained on various
aspects. They are given orientation to the organization structure and function, philosophy
and policy. The new staff is oriented towards the race, colour, culture course, which
raises awareness of one's own and other's prejudices and discriminatory practices and
their impact. Other areas covered are therapeutic environment, Group dynamics and
effective therapy.
Philosophy and Approach
All the three organizations aIm at rehabilitation of the mentally ill. Their
approaches differ because of the different philosophies followed by them. The three
organizations work on different philosophies with different approaches. MRF works on
the principle of behaviour modification. This approach attempts to change the behaviour
component of psychiatric disorders. In order to do this, the patient is encouraged to carry
out a behaviour that he dislikes but which the society approves. This is combined with
that of cognitive training that involves a change in their disordered ways of thinking.
Cognitive training and behaviour therapy go hand in hand. The therapists follow what is
called habit formation chart listing down the activities for each patient that enables them
to modify their behaviour.
MRC works on the approach of transactional analysis. In this approach the
patients are encouraged to relate to one another in a group. The half-way home is an
artificial community where one helps the individual to remain a social being by taking
118

more responsibility for himself and helping others share feelings while remaIrung In
communication all the time. The community acts as a therapist in helping to find one's
own place back in the community. Contingency management is followed to bring
changes in the patients' undesired behaviour. It is based on the principle that if behaviour
persists, it is being reinforced by certain of its consequences and if these consequences
can be altered the behaviour should change. Similarly, a desired behaviour is further
reinforced by way of approval and praise. These reinforcements are brought about
through token economy for desirable behaviours. Token economy method gives scores
for the individual on their various activities, like waking up early in the mornings,
exercising, hygiene, communication, alertness, etc. They are assessed on these activities
and then given cash incentives on the credits achieved. The cash incentive acts as an
inspiration to behave well.
RMS works on the philosophy of therapeutic community model. A stress is
placed on understanding the human personality in health and illness from the context of
cultural and social factors in addition to individual variables. The trans-cultural
differences in phenomenology, course, outcome and treatment of mentally ill are
synthesised with the dynamic interaction with cultural factors. Inter-dependence is used
therapeutically to a large extent. The cultural forms of dependency and dependability
are made use ofto achieve growth towards autonomy.
MRF's objectives are towards day care and long term rehabilitation. It has a team
of psychiatrists working throughout which is lacking in the other two organizations.
Their day-to-day activities are hinged predominantly around vocational training and
occupational therapy. The products made by them are sold outside. This is one of the
sources of funds for the organization.
In MRC, the patients are engaged more on day to day routine activities. Social
skills training and various therapies aim at rehabilitating the patients back into their
communities within relatively short span of say, 9 to 12 months. The patients are
engaged in various activities that equip them to get back to their families to lead a normal
119

life. The approach in MRC and RMS is to help patients to develop or regain social skills
training, which are more useful in their every day life. MRC depends more on volunteers
to run the programmes for the patients. The regular staff members who are present in the
organization number only three and every afternoon is filled with sessions conducted by
volunteers. These volunteers are not professionals in the field of mental health care but
experts in their own field, viz., drawing, pottery making, yoga, games etc. The
psychologist and the social workers handle the therapy sessions. RMS on the other hand
has a very well equipped team of psychologist and social workers. This group is trained
in the philosophy of therapeutic community. They show real expertise in handling the
patients. Volunteers are also involved but are given responsibilities related to handling
accounts and medicines. The experts handle the therapies. Every day the staff involve
the patients in innovative programmes that brighten up the patients. Each day is different
and one feels no monotony in their work schedules. Whereas in the other two
organizations, viz., - MRF and MRC, there is a routine and monotonous pattern of
activity that takes place every day.
The RMS philosophy works on the therapeutic community model. A great stress
is given on understanding the human personality in health and illness in the context of
cultural and social factors in addition to individual variables. One of the organization
staff describes their philosophy thus: 'The trans-cultural differences in phenomenology,
course, outcome and treatment of mentally ill must be synthesised with the dynamic
interaction with the cultural factors. Just like the individual personality that develops in
an attempt to resolve the basic needs, the society develops in trying to find a common
solution to individual needs, biological, social, cosmic, religious and others. The health
sustaining aspects of culture are illustrated by customs, rituals as well as by sanctions and
institutions. Cultural differences in beliefs about mental illness influences the course and
outcome of recovery from illness. Individuals vary within and across cultures in
personality structure and psychological mechanisms. Understanding intercultural
differences of the individuals, is essential to facilitate recovery of mental equilibrium of
an individual and his/her reintegration in the society.
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In the therapeutic community model, RMS has successfully used some of the
cultural attitudes in treating and caring for the patients. They are:
1. Dependability vs. autonomy.
2. Cultural patterns in communication.
3. Tradition and change.
Dependability is a key attribute of the Indian mind and culture. As children, there
is a strong dependence on parents and during the old age the parents depend on the
children. Thus, there is a continuous inter-dependence in the system
At RMS, this inter-dependence is used therapeutically. A good support system is
built up wherein the sick person's feeling of security is taken care of. The family is
involved from the day of admission of a resident in the whole rehabilitation process. In
the process, the family IS also helped in many different ways, i.e., emotionally, they feel
better equipped to cope with the sick person. The understanding of the sick person
becomes better. The culture at RMS makes them look at themselves as part and parcel of
the social system and have an ongoing close relationship with the society. This aspect is
made use of therapeutically in a number ways. The whole purpose of rehabilitation is to
send the individual back to his family and into society. In order to achieve this, the
mdividuals must be trained to make him function normally. The methods used are:
1. Family therapy
2. Integrating the individual back into the family
3. Public/social awareness of the mentally ill
4. Tapping all outside resources for placing the residents, i.e., jobs training, schooling,
skills training, etc.
Total dependence or total autonomy is not possible. During individual therapy
where a person learns to be inter-dependent, while enjoying the support of the family, he
also learns that he has to be responsible for himself. So, he learns that he has to have a
job, he has to look after himself, his family is there and will support hislher in all ways
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ut he too has a role in looking after himself.
In this manner, the cultural form of
dependency and dependability is made use of in an ongoing h'Towth towards autonomy.
Cultural patterns itl communication
Communication is a major factor and a problem in the area of mental health. In
schizophrenia, the experts have shown that symptoms are exacerbated when patients are
confronted with complex tasks but not so when tasks are simple and clearly explained
and attainable. Also, if a good role model is provided, the mentally ill finds it easier to
adapt to the normal way of functioning. In the therapeutic community, the staff role
models play an important role. The close proximity with which the interaction takes
place goes a long way in rehabilitating an individual resident. Thus, the culture within
the culture, i.e. the Indian culture and the RMS Houses co-exist.
Residents of RMS homes come from all over the country and have their own
family culture and background. The staff of the RMS homes also come from different
backgrounds and so attaining a consensus among all is a continuous and a difficult task.
Cultural differences among the staff are worked through staff dynamics and personal
growth sessions, especially where the attitudes are deep rooted and problem oriented.
For example, a female staff member coming from a very conservative family finds it very
hard to relate to male residents. This inhibition causes some disturbance for establishing
a healthy community life. Hence helping a person with this problem becomes vital;
however, this attitude helps in certain ways.
In India where the girls and boys are actually not allowed to mingle freely, where
many families have their own doubts of leaving a female resident here with other male
residents, find it very comforting when they find a conservative female staff. Thus there
is an advantage too. The whole communication pattern of the family is worked out
during the intensive family therapy sessions. During the stay in the RMS homes the
families participate in all the programmes, family sessions and actually experience the
importance of straightforward and direct communication. This helps them not to give
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dual messages, which lead to manipulation, but to be direct and expect open and honest
responses.
Tradition
Indian families are mostly very traditional and have a great deal of faith in
religion. This provides an anchor to hold on to. When their ward is sick the families do
not give up hope and try different means to ,get the.sick..child back 10 .normaL ,..This
perseverance and the optimistic hope in the families have to be positively utilised in
helping the patients by involving them in every possible way. Each time the home
receives a new resident from a different cultural background, it is a challenge to the
home, to all the residents and the staff to understand and adapt to the different individuals
and help him or her to get back to the family. Each resident thus provides a new lesson to
the organization. This constant challenge to adapt and learn helps the staff and the
residents to be flexible which is the password for peaceful co-existence in life.
Linkages with Government and Other Organizations
The founders of MRF are retired psychiatrists from the Government mental
hospital. The organization has as its members many of those working in the government
psychiatric departments. As such there is a very good rapport between the government
organizations and the voluntary organization. Many cases are referred by the government
departments to the voluntary organizations for follow up. Many families who are in need
of professional support for taking care of their wards are referred to these organizations.
Even after their admission in the voluntary organizations their respective psychiatrists in
the Governmental hospitals do the psychiatric follow-up, except in the case of those
patients in MRF, where psychiatrists are available throughout.
MRF is strongly linked with the Government Psychiatry Department and also the
Institute of Mental Health, and other psychiatry units all over India. The organization
accepts patients sent through referral from these organizations. The voluntary
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organizations send many of those who require psychiatric help to MRF. The network of
MRF with other voluntary organizations is also strong; it, therefore receives many
referred cases.
MRC's forte is counselling and training. It is also affiliated with other centres like
family welfare centres, Cosmopolitan club, the Government Mental Hospital
(NIMHANS) and has organised many joint programmes in the area that require
counselling, training, dissemination and advocacy.
However, since MRC also has programmes of rehabilitation, NIMHANS and also
Psychiatry units of other hospitals in Bangalore refer their patients to MRC. It also has
linkages with other half-way homes in the country which enables to exchange services.
This has been made possible by way of forming a 'Coffee Club', which meets on a
Saturday of every month. Representatives from other voluntary organizations are invited
and lessons are learnt from each other. This also facilitates critical assessment of the
work of the organizations and exchange of valuable suggestions.
RMS is constantly in contact with the Government Mental Hospital, NlMHANS,
as its founder is an ex-employee of the hospital and many of the psychiatrists are board
members of the organization. This organization has been recognised as a placement
centre for training the students of social work and psychology. There is a constant flow of
students from these departments to the organization. Most of the patients are referred to
it by the Psychiatrists for post hospital care and rehabilitation. The students of
NIMHANS also get postings in one of the centres after they successfully complete the
training courses. As there are no psychiatrists involved on a day to day basis in the
organization, the patients are taken to their respective psychiatrist at NIMHANS for
follow-up and regular check-ups.
On the whole, there is a good complementary network between the Government
and the voluntary organizations (VOs). The patients are mostly referred by the
government organizations. There is a continuous dialogue between the voluntary
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Organizations and the government Organizations, and the voluntary organizations act as a
bridge between the hospital, the half-way homes and the patients' families. They have
the advantage of getting services of a professional group of psychiatrists, from a premier
government mental hospital. There is a continuous flow of patients from the hospitals to
these organizations making them almost an extension of the Government hospitals.
Organization Resources and Funds
Funds for VO playa crucial role in determining their working strategies. They
have to struggle hard to acquire funds. The Government b'fants to them are minimal and
according to one of the members, 'Vol untary organizations depending on the
Government face many problems related to red tapeism and corruption. First of all there
is always a delay in receiving the instalments. If an organization wishes to be
independent and innovative, it is always better not to depend on the Government funds'.
Good leadership and good contacts have enabled MRF to obtain funds. Effective
leadership, teamwork and good contacts are a pre-requisite for mobilising resources for
an organization. Funding is a crucial factor also because it determines adequate
remuneration for the staff and infra-structural facilities for the patients'.
The main source of income for the organization are: public donations, interest
from corpus funds kept as fixed deposits invested by the organization, grants from
Government of Tamilnadu, advances on loan from Small Scale Industries Development
Bank of India (SIDBI) which helps in giving loans for various vocational training
activities, for instance, candle making, agarbathi making, chalk making, etc., Lion's club
and profits made through the sale of the products made by the patients.
Apart from the above, grants are also received from WHO, Johns Hopkins,
German Consulate, Helpage India. Searle India, Oxfam, IDRC, Bhasian Foundation,
M.K.Raju Fellowship and Jindal Aluminium. The families of the patients pay deposits
to get their wards accommodated in special residential centres, which are self-sustaining.
Part of the money thus generated also helps towards running the organization.
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Recently (1995), the Government of India has recognised mental illness as a
priority area to be administered under the Ministry of Social Welfare. This has been the
result of considerable amount of lobbying efforts by the MRF and the profession of
Psychiatry. Through these efforts more grants are expected from the Welfare Ministry.
The All India Women's' Association has agreed to bear the total costs of rehabilitation
for female patients from low-income groups.
The residential centres have been built on the lands donated by religious
organizations. The female residential centre has been donated by a Temple Trust and the
male residential centre by a Hindu religious Trust. Both the lands have been donated on
lease. SIDBI also offers help for setting up various vocational training units. A canteen is
run by the rehabilitated patients numbering eighteen at a leading educational institute at
Madras. Three vehicles have been donated by the public, the Lion's Club and the helpage
India.
Main expenditures identified are, 1. Medicines; 2. salaries for the staff; 3. infrastructure;
4. maintenance; 5. research and public education; 6. Transport; and 7.
others. According to the Administrative Officer, 'acquiring funds and planning the
expenditure pattern to set a smooth functioning for the organization has been a difficult
task. The state Government funds are usually delayed. Donor organizations expect
prompt and clear responses to their queries which requires an administrative system with
a high level of efficiency. Waiting for funds is inevitable especially from Government
sources'.
Voluntary organizations face many problems in obtaining funds, According to
the Administrative officer, 'Aids, Leprosy, Cancer receive higher priority in funding as
compared to mental illness. MRF faces many problems in recruiting staff, as salaries are
determined by funds and it is very difficult to get good professionals at low salaries,
Fortunately, many volunteers offer their services to the organization'. One such volunteer
who helps the organization in accounting observed, 'many of the organization's problems
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are due to inadequate funds to cover the running costs. In the general environment of
rising prices and increasing rents, the organization may have to dip into its reserves'. He
expressed great satisfaction in doing voluntary service for the organization.
The major sponsors of MRC are Church missionaries of different countries, the
most -significant· being the-Bnited--Ehurch of Canada, Bread for the World, GTZ, West
Germany, Kom Over de Burg, Holland, Jindal Aluminium, Bangalore and a Swiss
philanthropist who every year donates a large amount. They receive no funds from the
Government. Among the international funding agencies, Action Aid has sponsored a
Mental Health Information Centre. In the year 1980, Oxfam sponsored the development
of a teaching kit for the mentally retarded children. According to one of the staff, "Funds
from abroad have lessened to a great extent and at present the organization relies more on
individual donations." Many industrialists and Philanthropists donate funds to the
organization. The annual fete conducted by the organization is another source of income.
The sponsors of the organization especially the international funding agencies and
Christian missionaries send representatives to the organization to check on the
organization's activities on a regular basis. This is a normal procedure for the sponsors.
These representatives stay in the organization itself and make their assessment. They
have been stressing for more fund-raising activities. This organization has been
managing itself with the available funds. But in order to expand its services it needs to
focus more on fund-raising.
A major fund raising programme of MRC is organising fete twice a year during
which sales are held and the profit made goes as donation to the Organization. During
this fete, the organization receives all kinds of used household materials, furniture,
vessels, clothes, etc., from those who do not require them and put them on sale along with
other new articles, articles made by the residents, like pots, greeting cards, plants etc.
Public are also encouraged to put up food stalls during the fete and whatever the profit
made is used up as revenue by the organization. This fete is conducted every year and
attracts large crowds. This innovative method is not only a way of collecting funds for
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the organization but also a JOYous day for the residents, staff and the public. The
residents wait for this day each year to have some fun. The staff members are also very
enthusiastic and involve the residents in all the activities of the day.
The major source of income for RMS is from the parent organization, a society.
The other major source of income is from donations, interest from corpus funds kept as
fixed deposits and Manpower Grant from London. The running costs of the homes are
borne by the families of the residents. For Instance, the families of the residents of the
group homes have contributed deposits, which facilitates running the homes. Those
staying in the half-way homes pay resident fee which also helps in running the
organization. Apart from these, the recently started day care centre offers vocational
training to the inmates, whose products are kept for sale. The sale receipts contribute to
the revenue. The organization has recently offered a post-graduate course on
rehabilitation. The fee obtained from the students might also be a good source of income.
Major expenditure has been: a) salaries, b) travel, c) vehicle, d) food e) maintenance and
development expenses.
There is a remarkable expansion of MRF and RMS in terms of opening new
centres and extension of services. They have been exceptionally successful in sustaining
themselves and offering effective service. MRC, on the other hand, is sustaining itself
but one can see a slow down in the overall services. Some of their activities like
programmes on social prevention, training programmes for students, teachers, etc., have
lessened and there has been very little expansIOn in terms of size or centres unlike the
other two VOs. One significant difference between MRC and the other two organizations
is that while MRF and RMS offer long-term rehabilitation to patients, MRC offers only
short-term rehabilitation. Since MRF and RMS take large deposits for long-term
rehabilitation from the families of the wards, this major source of income is not available
to MRC to expand and extend its activities. MRC is sustaining itself and its present
activities mainly because it has its own building.
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Conclusion
The three organizations have similarities and differences in many of their
characteristics. In some aspects one scores better than the other. With the given infrastructure
and the facilities, the organizations have adapted their own approaches towards
the care of the patients and that of their families. Even though some of the objectives of
the three organizations are similar, each organization also has its unique characteristics.
The three organizations have specific objectives and their services are much focussed.
They are all placed in advantageous locations, Madras and Bangalore, where the
psychiatric activity is considerable. The Government mental hospitals in both Madras
and Bangalore provide very good services to the mentally ill. The linkage between these
hospitals and the three organizations are close and complementary. As far as leadership is
concerned, MRF and RMS have an advantage over MRC. The staff is highly
professional in MRF and the organization has the advantage of close supervision of
psychiatrists. The staff at MRC lack training and there are no psychiatrists involved in its
daily activities. At the same time, monitoring by the senior psychiatrist is very minimal.
At RMS, the staff is well-trained and the activities are closely monitored. As far as
sustainability is concerned, MRF and RMS have succeeded in managing their funds well
enough for them to expand through internal funding.. MRC still depends on external
funding. It is maintaining the original services but has not expanded due to lack of funds.
The organizations differ in their philosophy and approach and this influences them in the
way they function. Each organization has its own merits and demerits.
The positive traits of MRF are its efficient leadership, professional staff, their
success m mobilising funds. They also have some demerits arising out of their
expansIOn. In the words of a Psychologist of MRF ,'There is lot of freedom to do what
we want. Monotony is not there as we are free to introduce innovation. Inter-personal
relations are very good and planned team work is possible. The objectives of the
organization are clear, job satisfaction is high. Though the staff are under-paid, they are
well-trained and experienced. There is a humane touch in the care and treatment
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provided. The organization IS highly successful In training the staff In g1Vmg
professional services'.
In RMS and MRC too leadership has been a crucial factor. RMS has expanded
because of the 'entrepreneunal approach'. However, MRC has tended to be less
entrepreneurial but more humane. [t has tended to de-emphasise the technological
approach seen present in MRF and placed greater emphasis on the humane spiritual
dimension of creating conducive atmosphere for the patients. In fact, rapid expansion of
MRF has its critics.
At MRC, the organization is blessed with its own building and a lot of open space
which is one of the pOSitive traits of the organization. Many other voluntary
organizations lack this facility which leads to a very cramped up accommodation. It has
a beautiful garden which gives a very serene look. It has a very homely atmosphere that
keeps the patient and staff very relaxed. The patients and staff have good privacy. The
staff rooms and the patient rooms are far apart.
The "humane approach" of MRC has attracted many volunteers which has helped
the organization a great deal in sharing the burden of organising activities for the patients.
The volunteers come up with very innovative programmes. They are constantly engaged
with some activity or the other that keeps them very busy throughout. There is a very
good sense of discipline, punctuality and cleanliness in the organization. This is very
important as it reflects on the patients' behaviour. Programmes are very well structured
and the religious backing of the organization has a great impact on the organization's
activities in the form of prayers and strict discipline. It is a unique organization wherein
the Pastors and the Medical professionals have come together to achieve a common goal.
It has been successful in blending both the philosophies of religion and medicine In
bringing mental health to those who come to them for help.
Another important asset of MRC is the indoor auditorium, which is used for all
recreational activities.
This accommodation is lacking in many other organizations.
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Leisure, recreation and games are crucial factors in determining the health of people
especially so for the mentally ill. The organization has planned well in providing this
facility to the patients. The staff turnover is less and the staff members continue for long.
The main reason could be the housing accommodation provided by the organization. The
staff are indeed very happy to work in the organization and very few complain of low
salaries. The staff feel that one of the best traits of the organization is that it does not
insist on hierarchy and is free from the nausea of Government bureaucracy.
At RMS, the positive traits are the trained staff, efficient teamwork and successful
fund raising. The house manager of the organization summarises the positive traits of the
organization as follows: i. Flattened hierarchy, ii. Liberal atmosphere, and iii. Freedom.
Due to these traits, there is no power struggle among the staff. Each staff member is
dedicated and does his work with full satisfaction. Between the different professionals
there is no hierarchy and irrespective of the number of years of experience in the
organization, the staff feel free to express their views. Hierarchy, which blocks action and
progress, is not present in the organization and this is the major cause for the success of
the organization.
Due to these positive traits, there is a congenial atmosphere and dealings between
patients and staff, and they are free from tension. Interaction among the staff is very
good and healthy inter-personal relationships exist. According to the house manager, the
merits of the organization are: i. maintenance of professional quality in the care and
treatment of the patients, and ii. freedom at work level and healthy inter-personal
relationships.
There are a few drawbacks too, which are inevitable for any organization.
According to one of the founder members who is a Psychiatrist, 'the organization has
grown big in the last few years leading to compartmentalisation. Once the organization
becomes large, it is forced to bureaucratise its staff structure and compartmentalise its
activities. It gets into problems of red tapeism, which is typical of Government
organization, thus losing its charm of being small'. In his view, voluntary organization
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should be small so that its activities remain focussed on the objectives and it does not get
bogged down with bureaucratic systems that are inevitable with large organizations.
One of the founder members of the organization comments thus, 'it is not good to
diversify. It is like a jellyfish taking different shapes. The result of this diversification
often leads to the project not meeting the objectives as the people who conceive 1he
project are different from those who actually deliver. In large organizations, the
expertise of the higher level of professionals does not reach the grass root levels. At the
same time, the professionals tend to get bogged down with bureaucratic work. The
problems are less when the organization is small'.
Remuneration to the stafT is low in all the three organizations, in MRC due to lack
of funds and in the other two VOs because of the higher priority placed on expansion.
Those presently working In the organizations are generally dedicated and service minded,
since they get satisfaction out of the Job. However, in MRF and RMS, there is
considerable turnover among men because of the opportunity to earn higher salaries
elsewhere. There is no male Psychiatrist in MRF at present because of the problem oflow
remuneration.
Occupational Therapist of the organization feels that a great deal of improvement
could be made in this area. According to him, 'Involvement in vocational activities
would help the patients learn some skills and help him to earn some money which is very
Important for them. It makes the patients busy, active and productive. It also boosts their
morale'.
Staff turnover has been a problem particularly in MRF but also in RMS to a lesser
degree. One psychologist attributed the same to work pressure and low remuneration.
She commented, 'it is very difficult to work with chronic mentally ill. Treatment is a
long process, which ultimately gives few positive results. But the struggle to get a
positive result should go on and one should not get disillusioned'. The occupational
therapist of the organization expressed that though job satisfaction is there, it is
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frustrating especially when the patients undergo relapse, as all the efforts put on their
bettennent become fruitless. He added, "this also affects the personal life of the involved
staff and brings about disappointment and depression. Career-wise it does not help much
as the salary paid is low. There is no job security, which forces one to keep looking for
-----options and such a situation affects the male staff particularly. Women, however, tend to
stay on despite low salaries. Therefore, MRF and RMS are dominated by women. This
poses special disadvantage in dealing with the male patients'"
Salaries for the staff have been a problem for long. Due to low salaries many staff
members quit the organization. A Psychiatrist observed, 'Every time there is a change in
the staff structure, the organization undergoes a menopause stage and things settle down
only when the new team picks up on what was left by the previous team. This is a very
big disadvantage especially for an organization working for the mentally ilL Team work
and continuity of the team plays a vital role in the treatment and rehabilitation'.
One of the senior members of the orgamzation summarised the drawbacks of MRF
thus. 'There are many problems that have to be overcome by the organization. These
problems are: I. predominance of female staff; 2. overcrowding in the day care centre
and rehabilitation centres; 3. the hostels becoming like lodges; 4. day care centre
resembling a baby sitting centre; 5. dependence of the patients on the staff members 6,
less coverage of the lower sections of the population; and 7. money becoming the
criteria for treatment and not mental illness. These have to be taken serious note and
checked'. The answer seems to be to have smaller organization structures or smaller
autonomous modules that function as separate activity and cost centres. One of the
senior psychiatrist of the organization commented that there has been a conflict in
ideology regarding the objectives of the organization, namely, research versus
rehabilitation in the lines of custodial care. It has been felt by some that the organization
was concentrating more on rehabilitation than on research.
MRC fortunately does not suffer from the problems inherent in large size. The
major demerits of MRC are the following: It lacks a psychiatrist who can be present in
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the organization all the time. The programmes for the inmates depend more on the
availability of volunteers and alternatives are not being sought for. Though the
involvement of volunteers is a very good aspect, the organization staff should attempt at
conducting therapy sessions independently. The mmates can be engaged in useful
activities like candle making or screen printing which would help the patients learn a
vocational activity. This might help them earn a living when they leave the organization.
RMS has its own drawbacks. In spite of the wonderful services rendered by the
organization, some improvements are yet to be made. A major problem for the
organization has been· the lack of space for both patients and staff. At present, the
patients share rooms about 5-6 per room. This has to be improved. The organization is
expanding. When more sub-centres of the organization come up it is always better that
they are made independent units in managing their money and accounts.
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Chapter Five
VOLUNTARY ORGANIZATIONS AND PATIENT CARE
Each organization has a system of its own, which in tum, is a part of a super
system. Voluntary organizations working in the area of mental health are looked from
the viewpoint of a sub-system of a super system, which includes, psychiatric hospitals
both government and private, and private psychiatric clinics where the mentally ill are
treated. Voluntary organizations working in the field of mental health care derive from
the properties of the parent system, its objectives, roles, functions and structure. They are
then modified according to the sub-system's needs. As such, it tends to imitate the
professionalism that characterises the mental health care set up. Every professional has a
fixed role to play and is expected to fulfil this role without deviating. Mental illness has
been the domain of the psychiatrist for a very long time. His or her role is to focus all the
attention on the patient who suffers from a problem, which is perceived as more of
physiological and neurological in nature. This focus on physiological aspects alone
proceeded further into probing into the person as an individual being, trying to
understand the psyche of the person and his personality characteristics.
As an attempt to understand the problem of the affected individual, the individual
is looked at from the viewpoint of the individual as a social being. In this, the attempt is
towards understanding him against the background of his social set up. Thus, these
professionals have evolved into the area of mental health care.
Mental health care, originally the domain of the psychiatrists, gradually witnessed
the entry of psychologists with their tools of structured questionnaires through which an
attempt was made to understand the human 'psyche'. These tools have a fixed fonnat
and most of them run into many pages, involving exercises for the patients and various
questions to test the patient's abilities. This ordeal is a routine one for the psychologists
and the patient. It involves lot of time and requires patience from both the expert and the
patient. To an observer, it seems to be a very monotonous and boring procedure, the
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patient exhibiting lot of restrain over the exercise. The social worker, the later entrant to
the mental health care system, focussed the patient as a social being, to a certain extent
softening the rather mechanical hardcore approach of the psychologist.
Voluntary organizations attempt to dilute the strict hierarchical order of formal
organizations, so that each individual might contribute towards the fulfilment of the
objectives of the organization. When the hierarchy is strict and uncompromising, it is
difficult for those in the lower rungs of the ladder to participate fully and effectively in
the programmes. Thus, it is very essential to keep the organization flexible so that one
might expect freedom, creativeness and innovativeness in action and more intimate interrelationship
between the staff irrespective of the hierarchical order. Otherwise,
frustration sets in among the professionals, who are relatively lower in the system so that
they feel themselves personally involved. However, one can observe dissatisfaction
among the social workers, vocational instructors and the occupational therapists since
they work, invariably, under the professional guidance of the psychiatrists.
This routinisation of the profession in some ways creates feelings of alienation
among the professionals. The social workers feel like dummies when it comes to
implementation of some of the curative measures. Any creative thinking or innovation
seems to be impossible and unreachable for them. The technicians, who play the role of
vocational instructors, have similar complaints regarding their roles to improve the
patient's condition.
Gender seems to play an important role in the formation of the voluntary
organization staff The voluntary organizations apparently seem to be dominated by
female staff. Men who get recruited to the organization hardly stay for long. The main
reason, being that of salaries. As such, there is predominance of female staff and the men
are mostly employed in the posts of drivers, clerks, vocational instructors, the latter
already looking for alternative job placement. As such, there is a marked difference in
the job preferences of the sexes. Those who stick to the organization are mostly those
women who are from high economic class for whom the salary is not the only source of
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livelihood and men who are unable to get a better placement. The ratio between male
and female staff favours women
In spite of some drawbacks, the voluntary organizations are successful in serving
both urban and rural people of all classes. They are efficient in dealing with the families
and community imparting knowledge on mental illness and training them in coping skills
to deal with the patients.
Schizophrenia, the most severe form of mental disorder, is like the proverbial
sphinx that asks more questions than can be answered. Han Selyle paraphrased the
present state of our knowledge of schizophrenia: "Psychiatrists seem to know what
schizophrenia is but they don't know what is schizophrenia" (MRF Report, 1994). Patient
care goes through various phases. Each voluntary organization tackles each phase of the
patients according to the organizations' respective philosophies. Patient care phases are -
a) identification of the patients, b) programmes and activities for the patients, c)
therapies, d) vocational training and e) rehabilitation.
Phase I
Phase II
Phase III
Phase IV
Identification
Disciplining
-.. activities
Vocational
-.. training
Rehabilitation
This chapter will deal in detail with the different phases involved in patient care
and the way in which the organizations approach the same.
Patients ofthe Organization
After discharge from the Mental hospital all the patients return to their families.
The family members undergo great strain in taking care of their wards. They look for a
place to retrain their ill family members to get back to the normal routine. These patients
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who can neither be put into the hospital nor be taken care by the families enter the half
way homes.
At MRF, most those patients who come for help suffer from schizophrenia. The
patients hail from different socio-economic backgrounds and also from both rural and
urban areas. The poor and the rich find a place here for their mentally ill wards. In all the
three organizations the patients are referred by the psychiatry units of the Government
and private hospitals and also by different voluntary organizations. At MRC, the
patients are also referred by Christian missionaries and churches to the organization
which has good networking with them. The patients who come here for help suffer from
various mental illnesses and they are from all economic classes. At RMS, a majority of
the patients who seek help from the organization suffer from schizophrenia. The centre
also admits patients suffering from manic-depressive psychosis and personality disorders.
The admission procedures vary in the three organizations. At MRF and MRC,
those patients who are willing to go through their programmes of rehabilitation are taken
in with the families' acceptance. At RMS, however, the procedure is different. The
patients enter the organization to learn through the therapeutic procedures, their
respective ways of living. All the clients are amicted by one or another mental disease
and have been treated by the psychiatrists in the hospitals. Most of them are not
symptomatic when they enter the home. They come here for retraining into the every day
routine and to return back to their families.
The admission of the clients is made after the approval of the families. The
patients are given admission only after a trial of three days. During this period their
behaviour is observed to see how best they adapt to the new environment. Only if this is
satisfactory, they are given admission. The patients are reviewed every three months by
the staff. During these review meetings, the patients' parents or guardians are also invited
to give their opilllons. After six months, the client is sent home for a holiday to get
feedback from the family members regarding the performance of the patients and to see
their improvement. After their return, a feedback is received from the patients regarding
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their stay at home to assess how best they could accommodate them in their families. In
the subsequent three months, the clients are retrained by the therapeutic community to be
independent and fit to go back to their families.
In all the three organizations there is a predominance of patients hailing from the
middle class and upper class economic groups. There are a few from the lower income
group. The patients are charged an amount according to their economic capacity but in
spite of that one can observe that there are few from the poorer sections of the society.
This is probably due to the fact that the families of the patients are not in a position to
shell out more money for the care of the patients. The organizations too are not able to
subsidise beyond a certain point. Thus, the voluntary sector in mental health care is
unable to attract patients from the poorer sections of the society.
Identification of the Patients
Among the three organizations only MRF is engaged in identifying the patients.
This is probably due to the fact that identification has to be done primarily by a
psychiatrist. As we have seen earlier, only MRF has psychiatrists on its staff team. The
MRF team identifies patients in the selected rural districts and in the adopted slum.
These identified patients are referred to the day care centre of MRF or residential centres
wherever needed. MRF conducts many camps in the rural areas and slums to identify
those who are in need of help. MRF has done a very remarkable exercise in one of the
rural areas with the help of social workers, sociologists and trained villagers to identify
those in need of psychiatric help and rehabilitation. This has been dealt in detail in the
section dealing with community based rehabilitation (see page no. ). Apart form the
identified patients, MRF gets referrals from Government hospitals and non-governmental
organizations and clinics from different parts of the country. The various activities during
the rural visits an; -
1. door to door survey for identifying the mentally ill;
2. public education on definition of mental illness and the symptoms of mental illness;
3. advising medication to the affected individuals;
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4. educating the families of the mentally ill;
5. follow-up services for the already identified individuals; and
6. training of the local people as health workers;
In the rural areas there is no residential rehabilitation facility at present
MRC and RMS are not involved in identification of patients. Their patients are
the ones referred by the psychiatrists of government hospitals; private hospitals and thosereferred
by other voluntary organizations.
In all the three organizations, complete case histories of the patients are recorded
and the psychiatrists' remarks are also thoroughly referred in order to understand the
patients' condition. The parents or guardians are briefly explained about the objectives of
the organizations. With the acceptance of the patients and the parents they are inducted
into the programmes
Programmes for the Residents
The programmes for the residents not only differ in the three organizations but
also are focused on different themes. Some aim at training them on every routine duty,
some on social skills, communication, confidence building, decision-making and
socialising in a group. This training is very important, as these patients have to return
back to their families well equipped to lead a better life. Each organization focuses on
specific aspects.
At MRF, there is great stress on vocational training and occupational therapy. The
patients are trained in different skills that engage them the whole day. This training helps
them in getting jobs in the future thus helping them in their successful rehabilitation. At
MRC there is a structured programme throughout the week. Mostly volunteers run these
programmes. The major objective is to keep the patients busy and develop in them the
art of communication within a group, which is expected to help them in their process of
rehabilitation. At RMS, the programmes are aimed at therapeutic training for the patients
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to get back to normalcy. The programmes are based on day to day routines. Therefore,
the programmes of the three organizations are based on their philosophies. Some
therapies are common to all the three organizations and some therapies are specific to
some organizations.
Daily Routine
All the three organizations-llim aLtrainiDg-the. patients .intaking.care..ofiheir daily ........
routine. The focus is to make them independent and discipline them regarding their day
to day activities. In all the residential centres they are monitored throughout. Their
activities begin with walks, exercises, cleaning up, etc. At MRF, the residential centres
start the day with walks and exercises and most part of their day is filled with vocational
activities. They are not involved much in cleanliness and maintenance of the premises.
But in the other two organizations they are engaged in most of the activities of the
organizations, more so at the RMS. At MRC, the mornings begin with an early morning
walk of 15 minutes outside the home. This serves as a good exercise to the patients.
Many of them feel lazy to get up but the social worker shows no mercy on them and all
of them are made to go for the morning walk. Every beginning and end of the day is
marked by a staff meeting, which goes on for an hour during which all the staff is
present. The residents are given responsibilities like supervision of other residents in
turns, helping the cooks in the kitchen, maintaining cleanliness and order, etc. A
committee meeting is held once a week. During this, the responsibilities are allocated to
the residents and they are expected to perform their duties throughout the week till the
next change is announced. Their performance is assessed and they are given points for
the same. This ensures good performance of the residents and also imbibes in them a
sense of responsibility.
As training towards conducting themselves well at home after they return back to
their families, the patients are instructed and trained to maintain themselves, their rooms
and premises clean. The staff members keep a constant watch on the residents. Some of
them tend to waste food some eat very slowly. This has to be checked constantly. But on
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the whole, the lunch hour is very well organised and the residents are relaxed and happy.
All of them wash their plates and glasses. No one grumbles about the same. They seem
to have been habituated by the staff. Discipline and decorum are expected to be
maintained by every individual during the dining time and they are given ranks by the
staff. All the residents are given duties in turns to take care of the dining hall to supervise
the hall and to see to it that everything is in order.
The volunteers visit the Organization every day and conduct different
programme. The morning sessions are from 9.30 to 12.30 a.m. They concentrate on
current affairs during which the patients are made to share the news of the day. Each one
is made to read a news item and share it with others in the group. This helps them to be
alert on the current affairs and also inculcate in them the habit of reading a newspaper.
This exercise makes the patients get used to the normal routine of the day-to-day life. It
also keeps them busy and aware of the happenings around them so that they do not feel
cut-off from normal life. It helps in preparing them to get used to the normal routine
once they return home.
The counsellors consisting of one psychologist and three social workers arrive at
MRC early by 8.30. A.M. Their first job is to hold a meeting with the house parents and
the resident social worker who stays in the organization itself. They sit together and
discuss the incidence of the previous night to see if all the patients are fine or if anyone of
them is upset, moody, violent, etc. This helps them to take special care of these
symptomatic patients during the daytime. For instance, the house parents reported that
one of the patients complained of sleeplessness during the night and she seemed very
depressed and wanted to see her psychiatrist the next day. She felt very unhappy and
mentioned that she wanted to end her life. These mood fluctuations and depressed
feelings need to be given special attention. Though they are common among these
patients they need to be taken care of to avoid untoward incidents. These are made note
of by the counsellors and necessary follow-up is taken. This continuity of care is very
important and at no time these patients should be overlooked or else it may end in a
complex situation
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The other programmes during the morning sessions are teaching English, peer
group training encouraging the patients to communicate to each other and participate in
group discussions. The sessions attempt to build confidence in the patients to actively
involve themselves in the group. In the afternoons the patients are involved in painting,
doll making, yoga, games and gardening. The organization-has a big auditorium that is
used for all the recreational activities like games, dance, music, Yoga and others. It is
away from their living rooms and is very well ventilated. The patients feel very relaxed
in this hall and engage themselves in different activities. Volunteers conduct most of
these programmes. Social work students from the city colleges co-ordinate these
activities in the evening! as part of their curriculum. Yoga is taught by a professional
who has volunteered to do the same. The inmates are also engaged in gardening. The
objective of these programmes is to engage the inmates in some activity or the other and
to prevent them from being lazy and idle.
The core philosophy of the MRC is centred on . transactional analysis' and
behaviour modification. The various therapeutic activities offered in the organization
are, English speaking which enables the patients to have a common language to
communicate and to improve their interpersonal relationships. A volunteer from the
Theological College holds English speaking classes once a week. A person from the
Indian Cottage industry visits the organization once a week to teach the patients making
toys, pots out of clay and painting the same. He is a very talented person and is very
popular among the patients of the organization and the patients look forward to see him
and attend his classes. He teaches them the technique of how to make different kinds of
pots and allows the patients to try on their own. The patients initially rejected the idea of
doll making. But after encouragement was given to them, they got very involved. Few
of the patients are very good at their work and sincere. These dolls and pots that are
made in the therapy classes are later exhibited and put for sale in the Annual Fete
organised every year. The occupational therapist also teaches them how to make many
useful things out of waste that can be recycled.
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Women volunteers from the Theological College teach the patients drawing and
painting. They bring all the materials from outside, paper, pencils, colours, etc., and
encourage the patients to try out their talents. Most of the patients feel shy initially and
feel that they cannot do a good job in painting. With much encouragement from the
volunteers and the staff members, the patients get themselves involved-in the activities.
At the end of the session all their paintings are displayed on the notice board. This gives
the patients a feeling of self worth to see their work put up on the notice board.
Painting sessions have helped to bring about a transition in a patient from a hostile
to a co-operative state of mind. These sessions are thus aimed at bringing a transition in
the patients by way of simple techniques. These also help in making the patients active
and engaging them in creative work.
These sessions are therapeutic in nature as once the paintings are done the group
is involved in a discussion that demands them to be appreciative, imaginative, critical and
also to participate in a group. After the painting session is over, all their pictures are
displayed neatly on a board by the residents themselves, titled, dated and signed. After
this the group sits for a discussion about these drawings. Each one is asked to comment
about his picture and the picture he liked the most and the reason for the same. It is very
interesting to see how they rate these pictures. Sometimes they rate the pictures
according to their relationship with the person who drew the same. This helps the
therapist to understand the patients' relationships with others in the group.
The objective of this session is to make them imagine and create something of
their own and also learn to appreciate the good work done by others. This trains them to
get involved in a group. Some paintings also instigate deeper thinking in them. Beautiful
scenery drawn by a girl is very well appreciated and some say that it reminds them of
their childhood garden and every one agrees that it makes them feel so happy and
cheerful. There are also a few pictures depressing, for instance, with a huge face
tongue sticking put, coloured in thick black and red. These pictures also bring out the
thoughts that are set deep in the patients' minds as the following illustration suggests.
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Case 1
The resident who coloured the picture of a huge face expressed that he
was the man who kept threatening him that he would kill him. So he has painted
him and put a big cross over the painting in his anger. The resident is always
suspicious and worried and fears that one man is waiting in the corner to kill him
with a knife. His hallucinations often haunt him. This gets reflected even in his
drawings. Some in the group laughed at him saying there is no one like that
existing and he should not get scared. Some others believed his story. Through
this discussion the staff came to know the mental state of mind of the residents
and identified some who needed help in recognising their fears. Some others
could imagine the good and beautiful things so that they can be happy in life. The
residents were given ranking according to their performance and given a lot of
appreciation. The charts were kept in the dining hall till the next day.
During every programme, the inmates are encouraged to the maximum extent to
be at their best The staff maintain a friendly and homely atmosphere with the inmates
and a striking feature of the organization is that every staff member is addressed by name
and the house parents are called Uncle and Aunt This is expected to bring a feeling of
belonging amongst the inmates. The inmates are given maximum freedom within the
limits of discipline set by the organization Inmates are given individual attention and the
counsellors offer counselling to them frequently with lot of patience and care.
Habit formation chart and a system of recognising economy is followed to
encourage the inmates in CUltivating good habits. Points are given for every activity the
inmates engage themselves, viz., room cleaning, personal cleaning, games, Yoga, Art,
etc. The incentive in the form of cash is offered to the inmates by the counsellors on the
outing day. On this day, they are all taken for a movie or a picnic.
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Between the morning and the noon session there is a break for about an hour and
a half when lunch is served. During this break period, they all sit around and chat, some
of them spend their time sitting alone. Some of them keep pacing up and down. But a1l
of them are quite relaxed as there is no serious work to be done and the staff members are
not there to monitor them.
Newspapers and some magazines are kept in the centre lounge for the patients to
keep track of the current events. They do not desire to do serious reading but prefer to
chat with the other patients. This is the best time to have a talk with them, as they feel
really relaxed. They are at ease and conversation is easy with them. Some of the patients
come forward to talk out their problems. Most of the patients feel free to talk except for a
few who are suspicious. Some of them retrospect over their problem and share their
problems. Sometimes, it seems that they have no mental problem as they behave so
normally. They seem to be innocent victims of the dreadful disease as the following
illustration of one ofthe patient's illness indicates.
Case 2
Kumar is a young boy from Andhra Pradesh, aged 16 years. He comes from a
very educated and sophisticated family. His father is a leading doctor and they
have lot of agricultural lands in their native place where they live. Kumar is the
eldest child in the family and he has always been a very playful child and his
problems did not precipitate until he was 14 years old when he showed lot of
disinterest in studies. He often used to run away from school and his parents
often received complaints from his teachers. He was mistaken f(lf being playful
and undisciplined and his parents never realised that he suffered from some
mental problem. But as days passed by he became more restless frequently and
the family members witnessed bouts of anger from Kumar without any reason.
They were very patient with him and helped him cool down his tempers. He
proved to be more adamant and wanted things to be the way he liked and hated to
work. Most of the time he spent lazily lying around doing nothing. The suspicion
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of him suffering some problem related to mental illness flashed to his father only
when he abstained totally from school and studies and started physical violence
on himself and others.
A visit to the psychiatrist confirmed that he was suffering from schizophrenia.
Kumar is by nature a very loveable boy, very jovial but with varying moods.
When he is not normal, he becomes very restless, uses abusive language and
violence that makes living with him so difficult. This is one example of a case
wherein the affected person seems so normal but in reality carries a very dreadful
disease bringing the whole family into distress.
In the evenings, the patients are sent for a walk outside the campus. Most of them
are sincere and return home promptly. But some of them tend to stay out for longer time
and return later than the specified time. According to the staff, walking is not only a
physical exercise but also for building up self-confidence. When the patients are left
alone to go for a walk they return back happily that they are trusted and believed. But
sometimes, a few patients also exploit this opportunity.
During such times, strict action is taken against them and a consequence is
decided for them on the following day by the staff and the other patients. They are made
to understand that their behaviour is not approved by the group and deserves to be
punished. The consequences are decided collectively by the staff and the patients as the
following illustration from the case notes suggests.
Case 3
The next morning the staff members who were on duty the previous night
handed over the charge to the morning staff. While doing so, the information of
the late coming of some of the residents was informed and they decided to discuss
the same with the residents. During the discussion, all the residents were asked to
react to the evening's episode. Those of whom who came back early felt that
those who returned late from walk deserved a punishment and each one suggested
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many punishments and the most popular one was to cut their evening walk for the
next three days. The affected people became very upset but they were made to
realise their mistake (MRC, 1994).
The consequences of the misbehaviours are well thought of by the staff. They are
such that they make the patients realise their mistake and imbibe in them a sense of
responsibility. They also learn from the consequence that it is wrong to exploit the
freedom given. The residents are also told that If there is a repeat of the evidence, they
will be forced to supervise them during the walks. Thus, the walking exercise not only
serves as a physical exercise but also helps them to be more responsible and confident in
managing themselves.
At RMS the day starts very early by 6 a.m. All of them get into their jogging
costumes. They all leave the home and go for a jog for about 15 minutes. All of them
come back by 6.15 a.m., and are asked to do some exercises. The house officer teaches
some exercise to the patients. Except for a few who go as a group, all others go
independently. Some are lazy and do not wish to go for the jog. They try to give
different excuse like cold, stomachache, headache, etc. Invariably, they all like to escape
from the morning ordeal. The house officer, Charles gets up by 5.30 a.m. every day and
his first job is to wake up all the residents. According to him, it is important for the staff
to be prompt and be punctual before expecting the patients to be so. Most of them tend to
be lazy, unless pushed through some activity. It is a difficult job to wake them all up and
put them to work early in the morning. The other major work is to keep a check on them
to see that they all get back home in time. Some of them run away sometimes-causing
anxiety to all. In these kinds of instances, Lhe residenLs are warned. They are made Lo
understand the problems the staff members undergo as they wait for them to return. Most
of them realise their mistake and apologise. But few remain indifferent and repeat the
mistakes often. So to prevent future problems, strict vigil is kept on these patients. The
other patients are asked to keep an eye on these problematic ones and they are asked to
repOlt on the same after reaching the home. Sometimes, if a patient is found to be too
difficult, the house officer takes the decision not to send him out for jogging and make
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him do exercises inside the home itself According to the house officer, it is a very big
responsibility to supervise these patients and it is very stressful when these patients create
problems early in the morning
After the jog and exercise they get back to their rooms to get ready soon. They
are asked to be ready by 8 a.m. after finishing their morning chores and cleaning up the
rooms. Each room accommodates about 3 to 4 patients. They are made responsible for
maintaining their rooms. A person is made leader for each room and he or she maintains
discipline and cleanliness in the room. The leader of the room is questioned by the house
officer ifit is not maintained well. From morning 7 to 8 a.m., they are all busy doing the
cleaning work and getting ready for the breakfast and morning sessions.
The resident group of 20 members is split into many groups by the staff. Each group
is assigned with duties. They are expected to do these duties in the mornings. These
duties are 1. gardening, 2. cutting vegetables, 3. washing the plates and tumblers, 4.
maintenance of the living room, and 5. maintenance of the dining room. These activities
are expected to be performed by the groups after the morning chores of washing, bathing
and breakfast. This system of assigning different activities instils in them a sense of
responsibility. This helps them in the long run to maintain their own home once they get
back.
They are engaged in cleaning up the living space and the dining space. This is
monitored by the chairman of the group who is elected from amongst the residents of the
horne. The responsibility of chairmanship comes to each one of the patients in rotation.
The chairman checks on every job done by the patients and the house officer is relieved
of the supervision work. He/she has to mobilise the inmates to write a poem, a short story
or any thing that is creative by the inmates and put it up on the notice board. The role of
the chairman is a very responsible one. The staff members keep assessing his/her
abilities and the way he manages the affair. Some of the patients are afraid to take up
chairmanship as it involves a lot of work, alertness and responsibility.
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The house activities during the day are mostly paper cover making, coconut shell
carving, wire baskets making, greeting cards, wood works and other works like
embroidery, bead work, blouse stitching, rope work etc. The inmates have a schedule to
follow every day. Each day marks one activity for the inmates. During the afternoon
session, each day is filled with very interesting sessions.
Cognitive Re-training and Behaviour Modification
As part of therapy, the MRF team attempts 'cognitive re-training and behaviour
modification'. The patients are engaged every day in different cognitive training skills.
The techniques used are:(a) games; and (2) habit formation charts. Games are chosen to
suit the interests of the patients. The themes of the games are many viz., current affairs,­
to improve the knowledge and awareness of the patients on current events, sports, films,
music etc. In all these games, the patients are asked to identify a personality giving some
clues regarding that person. This helps the patients to recollect whatever is there in thememory.
Scores are given on the basis of their answers. The games are mostly organised
as team events so that the patients develop amongst themselves a competitive spirit and
also be helpful to others in their group. Habit formation charts attempt to modify the
behaviour of the patients by way of various kinds of incentives. Habit formation chart is
an innovative method, which gives points to the patients on the basis of their cleanliness,
punctuality, discipline, etc. The incentives include giving scores on the basis of which the
patients receive money as well as gifts to motivate alterations in their behaviour. The
patients are supervised by and instructed by two men and a woman.
Every patient who enters MRF is assessed on various parameters, such as I.Q.,
cognitive skills, memory functions, memory retention capacity, disability, personality,
thought disorders etc. Various tools are used to understand hislher present status. He/she
is then assigned to a team of three consisting of a psychiatrist, psychologist and a social
worker. The psychologist performs the disability assessment tests, which include
assessment of the level of functioning, self-care, occupational role etc. The social worker
writes up the case history. Tools that are used to assess the patients are questionnaires,
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exercises, Rosarch's Test and object sorting test. Once the assessment is done, the
experts decide on the course of action. The morning sessions, at MRF involve intensive
therapies, which are administered only in the mornings when the patients are fresh and
alert. During the afternoons, most of the patients are tired and therefore, made to relax
for a while. Staff members are involved in writing reports. Staff meetings take place in
the afternoons. During these meetings, the performance of the patients is discussed and
further programmes planned. Special attention is paid to those who are restless, or
exhibit other symptoms of illness. In the evenings around 3 p.m., the patients are
involved in various kinds of games. During these sessions they are divided into two
groups. Various games are organised which focus on improving the ability of
association, memory and encouragement to participate in group activity.
Family is involved at every stage of the treatment. Separate sessions are arranged
for them. Behaviour of the patients is monitored constantly. This helps to prevent
relapse. The relationships between the patients fluctuate. Sometimes they are friendly
and some other times they quarrel. Group dynamics among them is very interesting and
sometimes strange. Observation of their behaviour helps the staff to understand each
client's problems, attitudes towards each other, their capacity to tolerate, accommodate
and adjust in the group etc. The interactive behaviour of the patients with the family
members is also keenly observed which helps in behavioural re-training and
modification. The staff ensure that the patients are involved in vocational activities.
Therapies are designed according to the client's conditions. The patients are put under
observation. Their habits, areas of fluctuation, relationships with others are observed.
Their functional levels are also assessed using interview techniques.
Behavioural therapy is attempted wherein relaxation is given to the patients. This
is attempted to improve self-care. Therapies aim at streamlining their behaviour so that
they can lead a normal life and perform everyday activities without dependence and
tension. Once a week, group therapy is conducted which helps the patients to bring out
their inner feelings and emotions. The staff members observe each of their activity is
during the therapies and during the training exercises, which help them to a great deal to
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understand their emotional problems. These sessions give them a floor to speak out what
is in their minds. They also help them to open up and share their problems with others.
During the group therapies, all the staff are involved. The staff members motivate and
encourage the patients to get involved in the sessions. Personal adjustments and
accommodative behaviour are observed during the sessions. Psychotherapy is
administered in the normal course, to the patients in order to understand their problems
and help in solving them.
Role of the Psychologist
The role of the psychologist is very crucial as he/she determines the level of
disability of the patients. The assessment of the disability is done using the WHO
prescribed schedule on 'Disability Assessment'.
Once the diagnosis is done, the experts plan the suitable therapy for the patients.
Cognitive re-training is given to the patients by means of various exercises. Volunteers
also carry out these exercises. The followmg case illustrates one of these sessions.
Case 4
A volunteer was training a client aged around 20 years on English
alphabets and numerals. The client had lost her memory and she had to be retaught
all the basics from the start. The volunteer trained the patient by giving
different types of exercises like writing alphabets, showing pictures of the
alphabets and asking the patient to identifY, giving mathematical exercises like
addition, subtraction, etc., to make the patient recollect those lost in the memory.
One volunteer remarked, "working with the patients is very strenuous, as they
have very little concentration and memory. But yet it gives immense satisfaction
when they make efforts and re-Iearn what they have lost in their memory. To see
their improvement gives great happiness and encouragement to work with them".
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The Psychologist working at MRF at the time of our field visit was one of
the fresh enthusiastic graduates from University with a degree in M.Phil. Clinical
Psychology. This was her first employment and she felt very happy about the
same. When she first joined the organization she was involved in a project on
'Risk factors in the children of Schizophrenia patients', The project intended to
keep track of the lives of the children of schizophrenic patients to see if any
pattern of abnormality was present in them. She was given the job of sending
letters to the patients who had been treated by MRF. The study concluded that
there was psychopathology in the families and the effect of this on the children
was suggested as a follow up. Her room is well equipped though crammed up due
to lack of space as the following quotation from the field diary suggests.
"Her room was a low ceiling narrow room which had a cot to the right
comer. On the left side were a table and a chair where she sat to interview the
patients. There were some racks filled with books and instruments used in the
therapies. The room was located in the ground floor whereas the rooms of the
psychiatrists and social workers are there in the first floor. This was a little away
from the main activity of the organization and was not so comfortable as it lacked
space. The mterviews and therapies were mostly performed during the mornings
when the patients were fresh".
The therapies given to the patients are many. They are, namely, behaviour
modification or behavioural re-training. In thiS, there is an attempt to modify the
behaviour of the patients, which would help them in their routine activity and also help
them to perform better socially. To attempt at this, the problems of the patients are first
identified. This is done through various methods as the following quotation from the
field diary suggests.
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Case 5
One morning there were about three new patients in the organization. The
psychiatrist took the history of the patients' illness and the social worker took their
family histories. Later, they were sent to the psychologist one by one. The
psychologist got ready with her various tools to test their ability. Many tests were
performed on them. To mention a few, Memory and learning test. In this the
patient was tested for verbal reproduction. For instance, the psychologist gave the
patient a piece of paper that contained a story split in parts. The patient was asked
to read through the passage and then asked to reproduce it to test how much of it
was retained by his/her memory.
After making the patient read the story, the psychologist asked the patient
to reproduce the same. She was asked to read over and over again and to
reproduce the same after reading. This was repeated four times and the number of
memories of the patients was recorded each time. These four trials helped the
psychologist to understand the memory retention power of the patient. Then, the
psychologist performed the neuro-psychological test that consisted of many
questions. Against each question the psychologist noted down the time taken to
answer the question, the answer given and, whether the answers were right or
wrong.
Case 6
The patient under study by the psychologist at the time of visit was a person
in his late thirties who had difficulties in grasping and remembering. In the first
stage of the test he was able to fill up the blanks correctly in a reasonable period
of time. But as it became a little complicated he started mixing up the figures.
These results were recorded by the psychologist for writing up her assessment
report of the patient.
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These tests make the patients very tired as it involves lot of attention and
concentration from them. So, these are performed in two to three sessions
depending on the ability of the patient. The patients exhibit lot of fatigue and
tiredness and their concentration gets very much reduced as the session
progresses. The psychologist thus has to time her sessions in such a way her
assessment would yield proper results for the psychiatrist to follow -up. She
commented, "It is very stressful to work with the patients and it is good for both
the patient and me to take a break and then continue after a while. It is always
preferred to conduct these sessions during the mornings when both of us are fresh.
Invariably, the afternoons are meant for relaxation and the patients are asked to
rest for a while. During these hours we complete our assessment reports and
discussions with other experts.
The other tests performed by the psychologist are that of ideational fluency which
assesses the ability of the patients to form ideas logically. For instance, they are asked to
list out things made of wood, round shaped things, which make them think logically.
They are also asked to identify similarities and differences between objects. These tests
of mental status examination pose great problems to the experts as explained by the
Psychologist.
Case 7
Usha, a psychologist, seemed very tired after a hectic morning session with
the patients. During an interview with her she expressed the difficulties faced by
her. "One main problem faced in these tests is the problem of language. These
tests are mostly standardised in English. The patients who come for treatment
come from all over India and we have to be clear enough to explain the tests to
the patients in a common language so that we achieve good results. The other
problem faced by us is the difficulty in making the patients respond to the various
questions posed. Some patients are very unresponsive. They do not react to any
questions. In these cases we take note of the behaviour of the patients, give them
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adequate time to respond and also see if the patients can communicate by writing.
Some patients are over-active, restless and cannot be put to systematic
interviewing. In dealing with these kinds of patients we have to make a quiet but
confident approach that calms the patient and makes him co-operate. Some
patients are very confused and give very muddled answers and during these times
it is best to take the help of the attendant of the patient".
A Day with the Social Worker
The social workers at MRF have a busy day from morning till evening with various
kinds of chores to attend to. They have a separate room next to the psychiatrists' room
and close to the vocational training unit for women. This location helps them in coordinating
their work
The social worker plays a crucial role in bridging up the diagnosis of the
psychiatrists and the assessment of the psychologist The follow-up of the patients'
background plays a crucial role in the treatment. The role of the social worker could be
described as that of continuous supervision role, which involves constant touch with the
patients. The role of the psychiatrist and psychologists are more specific and focussed
and for a particular duration of time. The social workers are always on their toes keeping
track of whatever is happening to the patients and their families. The following quotation
from the field notes describes the role played by the social worker.
Case 8
Maria is an M.Phil. in Psychiatric Social work from a reputed institution.
She seemed very happy with her job. She expressed that she was thoroughly
satisfied with the work atmosphere. She felt her role as a provider of feed-back to
the psychiatrist and the psychologist was vital. She divided her duties at MRF into
two categories, viz., primary duties and secondary duties. The former consisted
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of registration of patients, follow-up, client care and making rehabilitation plan
for the patients. Secondary duties were to take care of the vocational unit of the
female patients, supervising their activities, budgetary duties regarding purchase
of raw materials and sale of products made in the vocational centre.
Of all the duties assigned to her Maria feels that the client registration and
follow-up are the most important ones. Every patient who enters the organization
is first registered by the social worker. All the particulars regarding the patient are
recorded, viz., - the identification data related to name, age, sex, religion, address,
language spoken, source of referral etc. The social worker then proceeds to the
history of illness, duration, details regarding the relapse, history of treatment
undertaken by the patient, etc.
Once the illness history is recorded, the personal history, viz., the date of
birth, order of birth, complications during birth, childhood psychiatric history,
emotional disturbances experienced during childhood, educational history and
academiC performance are taken note of
The patient and the attendant who accompanies are interviewed on various
aspects of the patient's life, viz., menstrual histOry, sexual history, history of
alcohol. drug abuse, occupational history, marital history, obstetric history,
physical illness and family history.
Family history plays an important role in understanding the patient's mental status.
The following quotatIOn from a social worker illustrates the importance of the family
history.
"Sociology that we had learnt during our course is put to practical use when we are
engaged in taking the family history of the patients. We take a detailed history of the
structure of the family, parental consanguinity. family history of illness, family finances,
family inter-relationship, etc.,. After taking down the history, we visit the families of the
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patients to do the follow-up. Wherever we find gaps in the information, we clarify them
during our family visits. Understanding the family milieu of the patients helps us in a
great way to understand the patients' illnesses and also to plan a suitable rehabilitation
programme for them".
After writing the case histOry, the social worker-takes notes on the mentaLstatus,
which is followed by the psychiatrist's clinical diagnosis. Another important role the
social worker performs is of behavioural analysis. According to the social worker, "This
is yet another area that needs to be probed deeply in order to understand the status of the
patient. Firstly, the problem situation of the patient is understood. His or her behavioural
excesses, behavioural defects and strong points are assessed. The frequency, duration and
intensity of the occurrences of behavioural excesses are tested. The behaviour analysis is
made keeping in milld the standard of socially acceptable behaviour".
The other areas that are probed are the motivating factors that instigate acceptable
behaVIOur in the patients, the key persons who have an influencing effect on the patients,
the incentive that the patients get attracted to and the major aversive stimuli for the
pallents. In the course of the analYSIS, the expert learns all about the behavioural
problems of the pallent and gets relevant information to plan for behaviour modification.
The following ill ustration from the case diary would make the exercise clear.
Case 9
Once during the interview with a patient, the social worker probed into the
patient's mind by asking what she liked the most. The patient replied that she
liked listening to music. This was confirmed from the attendant accompanying
the patients. The social worker asked her if she could change herself a little
towards the positive direction, then she would get a reward, may be a good music
cassette. The patient agreed to this and was very eager to change her odd
behaviour. The patient also expressed that she liked her father more than her
mother and would listen to whatever he says. But the patient seemed to hate her
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mother and was very violent towards her. In order to check the behaviour of the
patient, the social worker assured the patient that she would receive a reward of
her favourite cassette if she would listen to the good words of her father and also
be good to her mother. The patient gave a very happy nod for the same.
In these kind of problem situations, the patient's likes and dislikes are studied· to .
understand the patient's behaviour and help them correct and modify their behaviour
according to the socially acceptable norms. The discussion with the patient helps the
social worker to understand his/her relationship with the other members of the family.
This helps in planning programmes for the patients and their family.
The other areas of interest to the social worker are to do the developmental analysis
in terms of the biological changes that the patient underwent and whether they caused any
limitations in her behaviour, affecting her course of life. It is also important for the social
worker to know whether the patient underwent treatment for the same. The following
case illustrates a similar problem faced by a patient.
Case 10
Kala is a schizophrenic patient aged 30 years. During her adolescent ages
of 15-17 years, she exhibited many behavioural excesses due to biological
changes. For instance, she would go out of her house, sit on the pavement and
keep calling to young boys. She would ask them to sit next to her. She used to
long for physical proximity with boys. She would ask all the boys who passed by
if any of them would marry her. The parents took her for treatment but it did not
help her much. They received lot of complaints and humiliation from neighbours
and they were forced to shift their residence. The family members decided to
marry her off so that this problem would get solved. The doctor attending on her
advised them not to get her married as this was not the solution for her problem
and it would only complicate her situation. Only then the family members came
to know that she had a psychiatric problem. A probe into the developmental
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aI:}alysis tracing through the biological changes helps the experts in understanding
the problems of the patient. In spite of the doctor's advise she was married off
which caused severe problems to her. This is one of the cases wherein MRF has
done a family intervention programme to make them accept her disease and take
appropriate action.
The other area of importance to the experts is that of sociological changes. The
experts try to understand the features of the present socio-cultural milieu of the patient.
They look for changes in the milieu that are pertinent to his current behaviour and see
whether he experienced any role conflicts due to the change. Then they identify the
sociological factors that determine the patient's behaviour and use them in the treatment
programme. The following illustration shows how sociological changes in the patient's
family brought about behavioural changes in the patient.
Case 11
Mallika is a schizophrenic patient aged 30 years. She had a very happy
childhood. She lost her parents at a very early age and was taken care by her
relatives. When they grew older, she lived with her brother separately and her
brother was very good to her and took care of her very well. During her college
days, she used to have many friends. She fell in love with one of her college
mates and married him. But they had a very unhappy married life and it ended in
a divorce. After her divorce, she came back to live with her brother. She was
very depressed after her divorce and attempted suicide many times. Meanwhile
her brother's marriage was fixed. The news of her brother's wedding disturbed
her a lot. She was so possessive of her brother that she could not accept the fact
that he will soon be married. After the wedding, she was very angry with her
brother and started getting violent. She hated her sister-in-law and did not want to
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live in the same house. Her brother could not tackle the situation and decided that
he would leave the house along with her wife so that her sister would not have
mental upsets. But the situation became worse as she could not cope up with the
new situation and felt everyone had deserted her. The brother of the patient
sought MRF for help. This is a typical instance of how sociological factors, in
this case a marriage of a very close kith brought about disruptive changes in the
behaviour of a patient. These situations help the team to learn more about the
patient's family experience. It also helps them plan an action to make the patient
accept the new role and tackle the situation.
The experts analyse the behavioural changes in the patient that occurred as a result
of changes in the social, cultural and physical environment. They try to assess the selfcontrol
ability of the patients and how best thIS can be used in the treatment programme.
The other area of interest to the experts is that of analysis of social relationships.
They try to learn from the patient the most significant person in his current environment
and those whom he thinks creates problems for him and those who reinforce the
behaviour in him. Once they learn who the significant person is in the patient's life, they
call himlher over and involve him in the treatment procedure. They learn what the
patient expects from the significant other and what the latter expects form the patient.
The involvement of the significant others in the treatment helps in influencing the
expected behaviour in the patient. The social workers also try to understand the
normative milieu of the patient and the behaviour of the patient. They look for the
lImitations in the patient's environment that exacerbate abnormal behaviour. Ifthere is a
support in the social milieu for changes in attitudes and values, they make use of them in
psychotherapy.
The social worker thus helps, to a b'Teat extent, to fill up the diagnostic gaps. The
notes of the social worker are of vital importance to the psychiatrist to understand the
patient's illness from the point of view of his social setting. Whatever be the cause of
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illness, understanding the social milieu is very important in planning for the treatment of
the individuals.
Role of the Psychiatrists
The Psychiatrists of MRF playa crucial role in the diagnosis and treatment of the
patients. They take very special interest in dealing with the patients' problems. This is
usually a private affair involving the patient and the psychiatrist though sometimes the
attendant of the patient is also included. The case is then discussed with the other experts
of the team for follow-up and rehabilitation.
Case 12
Meera is a 45 years old psychiatrist, who has done her MBBS, DPM and
PhD. She is married and is employed at MRF for more than a decade. She was
previously working in the Government Psychiatry department on a project. She is
the Joint Secretary at MRF and second in line for leadership. In the absence of
the Director she will have to take up all the responsibilities and as such according
to her, her work is more administrative in nature. She is also involved in research.
She contributes to the out-patient consultation, in the rehabilitation meetings
where discussions on plans for each patient are conducted. She also joins in the
planning of public education programmes. She feels that the most important of all
her duties is mobilisation of funds to run the organization.
According to her, when MRF was just two years old, it was very easy to
acquire funds because it did not require much money. But. at present, since it has
grown very big, even if funds come in lakhs, it never seems to be sufficient. Very
few foreign agencies fund the organization. She hoped that the Central
Government would help the organization with some funds as the dispute
regarding funds for the mentally ill has been settled. This was settled after much
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lobbying by the MRF representatives with the Ministry of Health and Ministry of
Welfare and the responsibility has been given to the Ministry of Welfare.
Regarding the families of the patients, she feels, "some co-operate and
some don't. So it gets very difficult to convince the families first and then the
patients. She strongly feels social stigma against the mentally ill still prevails
strongly and this would take a very long time to get diminished. Some parents
agree to co-operate and listen to the psychiatrist's plan of action. But once they
get back home they create problems to the patients. It is very difficult to get the
family members to understand the illness of the patients and make them cooperate".
She is very disappointed with the way things are gomg on m the
organization. According to her, "the interpersonal relations are not so good. The
higher personnel treat the lower grade staff very badly. Though they are actively
involved in treatment, they are very business like and do not show much love for
the patients. This is a recent trend and it was not so before. The staff who have
joined recently are more self oriented and not interested in servicing the patiettts.
Patient care quality has come down. There are no outings for the patients". She
seemed very worried that the organization was deviating from its objectives and
becoming a moneymaking set up. She personally felt that the organization should
not be used for individual benefits. The cause should always be remembered and
the motive should always be 'social service'.
Committee Meeting
At RMS, during Monday afternoons, there is a committee meeting, where the
review of the activities of the previous week is done. All the inmates are made to react to
the previous week's happenings. The staff members tactfully pose questions to the
inmates about their performance during the previous week. The inmates are asked to
respond to the chairmanship of the previous week and it is an interesting session which
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helps the staff to understand the capabilities of the inmates, their capacity to maintain the
group, their leadership qualities and also their interpersonal relationships with the other
patients. At the end of the session the group is asked to elect a new chainnan for the next
week. This exercise gives the inmates an opportunity to take up responsibility in running
the home and also instils confidence in them and removes fear.
Monday afternoon is spent in reviewing the perfonnance of the chainnan of the
previous week. The chairperson of the previous week is asked to speak out the problems
faced by him in the ,last one week. The other staff are also asked to comment on the
chainnanship, hislher positives and negatives and the ways to rectify the same. The
following case illustrates one of these sessions that assessed the old chainnan and which
elected the new one.
Case 13
It was a Monday afternoon. Everybody had finished their lunch, relaxed
for some time and assembled in the living room by 2 p.m. All the staff
assembled too. The chainnan of the previous week was very smartly dressed and
eagerly waiting for the responses of the other patients and the staff regarding his
role perfonnance. All of them sat around in a circle and each one of them reacted
to his chainnanship. Vijay was the chainnan for the previous week. He is one of
the playful and jovial patients around and a very popular one too. But he is too
casual with all the work and the reactions of the others were very interesting. All
the residents appreciated Vijay for his good chainnanship. All felt that he had
been very good with his work as a chainnan, which was very surprising. They all
appreciated him and asked him to continue to be efficient even though his
chainnanship had ended. He was beaming with joy by all their appreciation.
Some others did point out to some of the problems they faced during his
chainnanship. Their main complaint was that he seemed to have patience with
some boys just because they were his friends and gave them less work and never
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checked on them. Surprisingly, he agreed with the same and said he did not know
how to be stem with them as they were his friends and said he would try to avoid
this during his next opportunity. One of the staff members pointed out to him that
he failed to wake up early in the morning to start his chores and this was very
incorrect, he being the chairman of the group. He added that the chairman should
act as a model to be followed by the group and not be a bad role model for the
group to excuse themselves from doing things.
The session was very balanced with the members making both positive
and negative comments. They appreciated all his good work and pointed out his
mistakes for future improvement. V felt fine. He expressed his satisfaction over
his chairmanship and thanked all the patients for their co-operation during his
chairmanship. All the patients were feeling very happy about the same. One of
them remarked, "It is nice to see Vijay so responsible and serious as we have
always seen him joking and so playful. None of us ever thought he could be such
a good leader. Throughout the session, one could observe that each one in the
group was expressing their feelings very freely and frankly and no one was
getting angry with the other. They took all the comments in a very healthy spirit.
Then it was decided to elect the new chairman for the next week. The staff had
already decided on the new chairman. This selection is based on the fact that the
person who is selected needs to be exposed to some responsibilities. Also, they
choose the person in such a way that the selected person overcomes the
complexes and mixes with the crowd freely. The idea behind the exercise is to
build confidence in the patients and also develop a leadership quality in them. It
also helps the patient to socialise well in the group. They take care not to
overburden patients with responsibilities which might disturb their mental status.
Vocational Training
At MRF, Vocational training is given to the patients of day care and rehabilitation
centre on various skills. The various activities run by the centre are screen-printing,
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paper printing, baking, stitching, etc. The products obtained from their work are sold to
outsiders and also used for office requirements. These jobs are done for outsiders on
order. Profits from the sale are used by the organization. The patients are given an
incentive in the form of cash according to the labour done. The MRF team is constantly
engaged in developing contacts. The instructor in charge of the vocational training"
observed, ' 'The patients are mostly very slow in understanding and their self-confidence
is very low and getting their co-operation is the most difficult task. We at MRF are
trying our best to improve contacts to attract more demand for the products made at MRF
which would help the patients to keep themselves busy and also help the organization
gain some revenue'.
The patients are trained to make purchases, maintain accounts and also deliver the
products. This involvement develops lot of confidence in them. They also learn to
maintain their own accoWlts regarding their earnings and expenses. Incentives are paid to
them to make them feel self-reliant. One of the patients remarked, 'The incentives that
are given makes me feel that I too have a status in this society like a normal person and
can make money out of my work. I hope to work hard and make more money'.
The instructor, who involves them in activities, is a very efficient and enterprising
person who involves all the patients in activities. He facilitates interaction among the
patients and prevents them from getting into boredom and sulking. The chief activities
Wldertaken by the male patients at the MRF Day care centre are printing of pamphlets,
visiting cards and invitations.
Printing is one of the main vocational activities for the male patients at MRF. The
centre takes orders for making invitations, visiting cards, candles, agarbathis, envelopes
and phenol. The patients keep themselves very busy and the room is full of activity. The
following quotation from the field notes illustrates the activities in the centre.
"It was a hot summer afternoon, all the patients were busy with some work or
other. Three patients were making incense sticks. Five of them were near the printer
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arranging the printing blocks. The instructor was having a tough time getting some
silence in the room. All of them had something or other to talk. Some of them teased the
others saying that they do not have any brains and they cannot do any work. This
accusation brought about lot of commotion in the room. Raghu, the instructor brought
peace amongthem-with lot of efforts: Though there seemed to be commotion always in
the vocational training rooms, as far as their work is concerned, they performed them
very meticulously". The following case illustration suggests their efficiency at work".
Case 15
One of the male patients Ramu is known for his seriousness and liking for
being alone. He does not mix well with the group but when given a job he is
serious about carrying out the duties. He has been a schizophrenic for about ten
years and his family sought the help of this organization after being referred by
the psychiatrist treating him. The main problems the family faced from him, were
his closeness and solitude, refusal to mingle in a group, his inability to socialise.
He is very violent if addressed to. His family members really get scared in his
presence. What he required was professional help to modifY his behaviour.
Therefore the family chose to get him to the day care centre where he could be
spending his time usefully. According to the vocational instructor, he was a very
talented person and very hard working. A small tease or fun making from anyone
would make him lose his mind. He got very moody, silent and depressed and
went into bouts of anger.
At MRF, the statT gave him the responsibility of managing the printing
work, which would mean taking orders and delivering the goods in time. Since
Ramu was a meticulous person, the orders were done to perfection. The patrons
who had initially refused to place orders since they would be made by mentally
ill, were too glad to get them done here as Ramu managed to complete their work
promptly and perfectly. Throughout the day, Ramu was and still is busy with his
work, which kept him preoccupied. He was forced to take assistance for the
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various tasks involved, this has given rise to a peer group of helpers. His violent
behaviour is now much under control as he is the boss in the group. Sometimes
he does show his anger but soon gets over it. According to his family members,
after attending MRF, he is more accommodative at home and they feel so relieved
about the same.
Female patients are involved in basket making, embrOidery work on tablecloth,
handkerchiefs and other ornamental items like dolls and handicraft products. Their room
is quieter as the following quotation from the field diary suggests.
"The girls are very busy doing either stitching or embroidery work. All of them are
sitting on the floor. Two of them are busy in the sewing machine stitching up the sides of
a beautifully embroidered tablecloth also done by a patient. In contrast to the men's
room, this room is very quiet, rather dull but the patients are all very involved in some
handwork or other. Some of them are weaving baskets with plastic wires. Some are busy
embroidering white handkerchiefs. The embroidery being made on these handkerchiefs
looks so delicate and makes one wonder the amount of concentration the patients have to
put in to produce such an intricate handwork".
The instructor of the female vocational unit is a very talented and a dedicated
person as the following case illustration suggests.
Case 16
Mary is the supervisor of the female vocational training centre. She has
been working at MRF for more than ten years. She discontinued her studies after
her eighth standard and underwent training in a Sister's Convent in Tirunelveli
and taught in a Christian Missionary School for sometime. She is very pious and
god fearing. She owes her patience and tolerance to the God's wisdom as she puts
it. She works from morning 9.30 a.m. to 4.30.in the evening, spends all her time
with the patients, eats with them and rests with them. She commented that it was
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only because of God's wisdom, she was able to take care of the patients. All the
patients loved her. She said, 'My service to them should be such that, they do not
hate me'. Basically, her work is to make the patients work. She has been trained
in many skills by MRF. She is an expert in handwork. She teaches the patients
embroidery, cross-stitch, knitting, tailoring and· basket weaving,·· Many years'
back MRF ran a canteen in the same premises and she was managing the same.
On an average about 15, female patients are taken care by her each day.
Patients who attend MRF are of various natures. According to Mary,
"Some are really interested in work, learn it meticulously. Some are very lazy and
simply doze off Bust most of them are very moody and to manage them requires
lot of patience. Whenever they are upset, they tend to become very violent".
Mary is always known to be very patient and tactful with the patients. She can
manage all crisis situations without any fear as the following episode indicates.
Another case of exchange in the behaviour pattern of the patients, who participate
in vocational therapy, is given below,
Case 17
One female patient Mala, aged about 18 years, has been suffering from
schizophrenia for about 4 years. One day she was in a very nasty mood.
According to her family members, she is always very paranoid about the people
around her. She is very troublesome at home as she always complains that
somebody is going to kill her. She disbelieves all her family members. She
spends all day long anticipating that all around her would harm her. She seemed
very angry with her family members for leaving her at the day care centre. She
was murmuring that everyone was making her mad by putting her along with mad
people. She was very upset. Mary, the instructor tried to pacify her. She told her
that she must be very tired because of the hot day and offered her juice. But Mala
got very cross with her and said she was trying to kill her by mixing poison and
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hit her on the head with one of those embroidery kits. Maria coolly took the juice
back and sat in her place. All the staff became a bit worried. But she told them
not to worry about her. After ten minutes, the patient came to her and started
justifying why she hit her. She said she was very suspicious with her mother for
sending her to MRF that day and she thought she has been sent only to be killed
by mixing poison in the juice. The instructor keeps her busy with some
handwork or other so that she would not engage in violence. Thus, the violent
patient is kept busy to avoid violent outpours. An event like this is very common
in these centres as the patients are very suspicious in nature and according to them
nobody is trustworthy and good. Whenever they experienced these mood swings
they get very upset and violent. The staff members are usually prepared for the
same. Mary has been with the patients for many years and has learnt by
experience to put up with their mood variations and violence.
She is very free with the patients, attends to them patiently and teaches
them good work. The patients too talk out their problems freely to her. They take
her as a very friendly person. Mary is very religious and takes her work really
seriously and never wants to leave the organization. She has got job offers from
many places for teaching handwork for school children and she has put down
these offers. She feels it is god's will that she should help these patients and so it
shall be. Though her remuneration is quite low, she feels it can keep her through
as she is unmarried and has no family commitment. She has lot of reverence for
the Director of the organization who works so hard for the patients and feels she
should also work like her selflessly.
The other programmes conducted for the wards include games that aim towards
making the patients aware of the current happenings. These games are conducted during
the evenings. Badminton and volleyball are other games to keep them physically active.
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Art Therapy
Another thing that involves the patient and the staff in a group is the art therapy.
This is conducted once a week at RMS. This is an interesting session, filled with a lot of
joy. At the beginning of the session, it looks like it is going to be like any other art class.
But at the end of it, one realises the therapeutic effect it has on the patients .. Raju who
organises the group therapies also conducts these sessions. He has undergone training in
various therapies and he has mastered in all these skills. He plans for the sessions very
systematically and has in mind the outcome that he hopes to get out of the sessions.
Excepting for one or two among the staff who help him organise the sessions, others are
not detailed about the session. So each session of his holds lot of surprise for the patients
and the staff. This is clearly seen in his session. The following quotation from the case
diary illustrates one of the art therapy sessions.
It was afternoon and all the patients and the staff had finished with their lunch,
patients relaxed for a while. During that time the staff members were busy sorting out
their chores, discussing the day's programme, sharing their experiences of the morning
sessions. Since it was Tuesday, R got ready with his art kits, briefed the social workers
about what he intended to do and everyone got ready for the art therapy. All the patients
assembled in the downstairs hall. Some were eager to know what was new for the day's
session. All of them sat down for a while. Raju started the session with a casual talk on
art and painting. He asked the patients whether they all liked colouring! painting. Some
gave positive nods and some said that they were very bad at art. Raju went on to say, "art
is a powerful weapon that can bring out what is in the mind. A person performs an art
activity for the sake of his or her own self. It should not be mistaken as done for others, -
as a piece to be exhibited to others. It is a piece of work done by the artist to fulfil his
desire". Thus, Raju created an impression in the minds of the patients that everyone in
this world are artists and each one can bring out his piece of work for his satisfaction and
happiness. So aU the patients were very much inspired. The following quotation from
the case diary illustrates how the therapist conducted the session and brought out positive
outcomes.
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Raju showed them a bowl filled with Indian ink and a tray filled with paintbrushes
of various sizes and chart papers. He told the patients to use the ink on the paper either
by brush or by hand and do whatever they felt like. Initially, the patients were a bit
puzzled, as they were not sure if they liked to use black ink but they had no other chOIce
and they started doing what they liked.1taju told them to feel free doing what they liked.
He put his hand in the bowl and with the ink that stuck to his hand he spread it on the
piece of paper. He did his own designs on the paper using his hand. This took the
patients by surprise but they felt very encouraged. They got busy with their chart paper.
As an onlooker and a participant, it puzzled me as to what therapeutic etTect this black
ink could probably have. This query was answered after an hour at the end of the
sessIOn.
Raju let them all free for a while making them play and experiment with the
colour. When everybody was exhausted, he began the discussion of how each one in the
group felt. The patients came out with ditTerent comments like, - initially, they were not
happy to use the black colour, somehow it did not attract them but slowly they got used to
it and made some art work out of it. One patient commented, "I felt happy to use the
colour the way I liked as I felt that no one is going to question me because you said that I
have to do this just for my sake". He had made lot of handprints on the chart paper and it
indeed looked very nice like a textile design and many appreciated it. The patients were
questioned if they had anything in mind when they started with the colour. Most of them
replied that fear of starting was there but soon they got over it. When they were asked if
they had anything in mind to initiate in the chart paper, some felt that they imagined
something but ended up doing something else. Some said, they just kept doing whatever
came to their minds. Some patients had drawn some nice cartoon figures and said they
felt happy. Some had drawn angry, devilish faces. They accepted later on that their state
of mind was not so peaceful and they felt frustrated. Some had created abstract figures
and they had no explanation for the same except to say that they were confused as to
what to do. Some said they felt very dirty to use the ink by hand and so used the brush.
There was lot of variety in the work produced and every one was happy to communicate
the same. They were asked individually to explain what they did and how they felt while
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painting the same. It was interesting to observe that all were involved In the activity and
no one felt left out, lonely or Isolated. It was a nice group and each one worked on his
own imagination with lot of confidence
The patients were asked to comment on each other's work. RaJu made the point
very clear to them that living in a group expectLthaL comments.Hof others, be it
encouraging or discouraging, have to be taken up in the right spirit and this is the essence
of community living. He analysed the whole session thus, "Perception of people are all
different. Each one perceives in his own way. For instance, the colour black has mostly a
negative connotation but it is up to the perceiver to decide whether it is good or bad". He
showed some charts that looked so beautiful on the white sheet of paper and explained to
the patient how black can look beautiful. There are people, who love black, prefer black
dresses, back bags, etc. Therefore, it all depends on the perception of the individuals.
Similarly, he highlighted and compared different perceptions of individuals. He gave
them examples from the organization itself as to how each one thinks of the other. He
drove the point that every one is good in this world and if one thinks that the other is bad,
it is only because of his perception. So, it is always better to think of the other person as
good and not harm him.
He explained to them on what is art and how important it is for people to express
their feelings freely. It gives great joy to be what one wants to be. Expressing what is in
ones minds on a piece of paper through art is very easy. That is why he told them he
wanted them to do what they liked on the paper. The patients agreed that It did make
them fearless as they felt that they were free to do what they liked. In real life, R
explained that in real life ones activities are commented upon as it is so with the piece of
art. So, it is best for the patients to take note of what others say. Any mistake pointed
out or advices given have to be well taken in a good spirit. Thus, the therapist brought
the art and life of the individual as a simile and capitalised on the therapeutic factors of
group therapy and made it an introspective session for the staff and the patients. The
highlight of these therapies at RMS is the active involvement of the staff and the patients
in all the sessions.
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One Tuesday afternoon, the therapist specialised in art therapy, distributed papers
to the inmates and asked them to imagine masks and make them on the paper. Some
were very moody and reluctant to start first but slowly joined the group and the inmates
were happy and were involved in cutting, pasting and colouring. Each one had his own
imaginatiorr.··&mre made masks in black, some did it colourfully; some madc:-the-lnasks- . _ ..
look angry, etc. Later on, the inmates were asked to describe their masks and comment
on them. The inmates responded very welL Some said they were happy to make them.
Some others said that they wanted to make an angry face and admitted that they were
unhappy inside and that could be the reason for them to have done the same. The
therapist made each of the patient think about each one of their masks and introspect why
they made such a mask. It is very interesting to observe the way the session transcends
from an art session to that of introspective analysis of each one of the group member.
Everything is discussed in a group and each one in the group is encouraged to talk and
comment freely on each individual's work.
Thus, the therapy makes the inmates reflect and introspect and express their
present state of mind. This session gives the staff much information on the inmates'
behaviour and also helps inmates express their feelings in a media associated with fun
and joy.
Cultural Show
During Wednesday afternoons, the inmates of RMS are engaged in planning for
the monthly get-together of the two homes. They plan for the cultural show, decide on
songs, dance, and dramas and practice the same. The staff members encourage the
inmates to get involved in the activities. These get-togethers are planned to bring out the
talents in the patients and make them feel important on that day. It boosts their morale
when they are appreciated. It is also a change from the normal routine as they meet the
patients from the other home and have an enjoyable day. The patients from both the
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homes give cultural programmes and entertain all. The staff members take great care in
training the patients and the volunteers help them in many ways. Some of the volunteers
sponsor for a special food item on this day. The inmates of the home where the event is
held choose the menu. The two homes take turns in being host to the get together party.
It is a joyous day for all as the following quotation from the case diary suggests.
'It was a Saturday and all the inmates of the city centre ofRMS were very excited
as they were getting ready to go to the party at the suburban centre of RMS. They had
planned many cultural activities and they had been practising very hard the whole month
to give a good performance. One of the patients who is known for his sense of humour
was dressed up as a joker and all the staff and the patients were so happy to see him
perform some acrobatics. One of the female patients had prepared for a vocal recital.
She had a beautiful voice but she was very conscious of her performance. She was tense
and anxious to finish her performance. She is one of the patients suffering from manic
depression and the staff had to often remind her not to get anxious and tense. There were
also some dance programmes organised and trained by the dance therapist. The patients
from the suburban centre had prepared a skit and one of their inmates gave a dance
performance. The programme was very enjoyable and the patients were all beaming with
great joy. The staff members also joined in various cultural activities and it all looked
like a great family get-together. The cultural programme went on throughout the
morning. Lunch was served and all the patients and the staff shared all the chores. They
relaxed for sometime in the afternoon. Later, in the evening, all of them joined to play
some games and by evening, all of them were exhausted and the guests left for their
homes.
As the house manager remarked, "These parties have a therapeutic effect on both
the staff and the patients. It narrows down the distance between them and within the staff
it dilutes the hierarchy as every one is involved in all the activities. The patients feel very
happy on this day, as they are free from serious work. The day is a motivation to all to
exhibit their talents. By way of performing they get rid of fear and build up confidence to
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face audience. This helps the patients a lot to face a crowd and also to mix in a group and
socialise well".
Group Therapy
Thursday afternoons at RMS are filled with another interesting session, - the
group therapy. During this session, all the inmates of the group assemble and the
therapist along with the other staff joins them. They sit together in a circle so that all the
members of the group can see each other. The group therapy aims at making the
members of the group share their problems in the group and get suggestions from the
group to solve their problems. It is based on the philosophy that once the members meet
in a group, they feel a sense of belonging with the /:,'TOUp and also show a preparedness to
share their problems and to seek solutions from others. They also feel better when they
come to know that every one in the group has similar problems. They learn from the
successes and mistakes of others in the group. They feel happy to be listened to and
helped by others. It gives them an opportunity to let out their strong emotions and
feelings to others. In the group therapy, the members take cues from the experience of
others to solve their own problems. This has been one of the successful therapies for the
mentally ill facilitating them to solve many of thm problems and also to develop trust
and confidence in the group.
Participation in group therapies brings in cohesiveness among the members of the
group. It also helps them in interpersonal learning, as they tend to share their problems
with each other. They all feel at ease when they come to know that each one in the group
has problems to face in hislher life. They come out of their solitude and express
themselves freely. On many occasions, the staff members share their grief/problems with
the group to make them realise that nobody in this world is devoid of problems. The
following quotation from the case diary suggests how the staff members share their
problems with the group.
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Case 18
It was one of those Thursday afternoons when all the patients waited
eagerly for the group therapy session. But that day the patients were very sad and
depressed as their staff member who conducts the sessions normally was
undergoing a traumatic life event as he lost his mother a few days back. He was in
immense sorrow as he was now left with no close family member since he lost his
father and his only sister earlier. The therapist did make it for work as he felt
working with the patients would help him heal from the wound sooner. The
patients were in a way happy that he would be conducting that afternoon group
therapy session.
The session started with a silent prayer for Raju's deceased mother. One
could notice that there were many tensed up faces among the patients. They all
seemed to be anxious to know what Raju would talk to them. Raju started the
session with a small note of thanks for all those who sent him condolence
messages. He spoke to them about how life events had a great impact on
individuals and he expressed an the feelings and emotions he underwent when his
mother passed away. He was so natural and spontaneous in his narration that an
the patients were completely absorbed. He shared with the group all the fears and
anxieties he underwent and how he was now trying hard to get over the same to
get back to the normal routine. He sent a clear message to the group that he was
undergoing a great trauma in life and it is common for all human beings to
experience these life events. It was very important to get over these and return
back to normal life. Another staff member intervened and asked the group
members to suggest ways to Raju so that he can get over the problem.
Each patient came out with his suggestions of how to get over the blues. It
was interesting to see how the patients visualised the situation and offered
suggestions, which any counsellor would have given to a patient under trauma.
These group therapies effective in influencing the patients' mind in realising that
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problems are universal and the members of the group have to be altruistic and
objective in offering solution to the problems of other group members.
One of the patients who is known for her mood swings suggested that R
should involve himself in some kind of musical activity, may be listening to
music or learning music which. might distract him from the depression. She
kindly offered him to teach veena, a musical instrument, which she was very good
at. Some patients shared their own experiences. One remarked that he was so
upset when his mother died at a very young age and suspected that his father had
killed her in anger as they were always fighting with each other. He was very
depressed and for a long time he felt like taking his own life. But he consoled R
that time will heal his wound as it did to his own.
Another patient who is very religious offered to chant a sloka that would
bring him peace of mind. She felt that uttering these mantras helped her
overcome many of her problems and she was sure that it would help R also. All
of them in the group seemed very concerned and the incident seemed to have
affected all of them. Each one offered their suggestions and also shared all their
emotions R was totally moved by the group. The staff came to know many of
the underlying sorrows and emotions of the group members as each one narrated
at least one of their life events that affected them most. The following quotation
from the case diary suggests how the patients come out with details about their
personal life experience.
'One patient Elisa, came out with very strong emotions about her personal
life. Elisa hails from a very rich family from one of the neighbouring states. She
was a very pampered daughter till the age of 8 years, after which her mother gave
birth to a son. The birth of the brother drew away all the attention from her to her
brother, which upset her a lot. When her brother was just two years old, her
mother passed away due to illness. She lost her father also when she was just 15
years old. All these events were so traumatic in life. She expressed to the group
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that she fought her way through all these hurdles only with the hope that her
future will hold something bright. She was so kind to M and told him to get over
his sorrows and think that 'the best is yet to be"'.
In some patients, the reminders of the past life events may make them more
depressed and the staff members have to take care to balance the session in such a way
that it ends well with a positive note, rather than making it worse for the vulnerable
patients. Raju, the therapist conducts the lessons in such a way that no one has any hard
feelings and they all end up finding solutions for each other's problems. Thus, these
sessions are introspective, as well as therapeutic.
Raju expressed great satisfaction after the session. He remarked, "1 felt so glad to
get counselled by our patients and this is the effect the therapeutic community is expected
to show. Sometimes, 1 was a bit anxious when some patients became very emotional
about their own life events and I hoped that it should not end up in a negative fashion. I
feel so happy that all ended well". He commented that each therapy session was a great
challenge to him to drive the group in a particular line of thought and it involved a lot of
planning. Though he knows the course of action, he conducts the session in such a way
that the others in the group feel that the session evolved out of a current problem. Each
session begins with the illustration of a problem and goes on towards evolving a problem
solving technique. The process is all in the hands of the therapist who runs the show. On
many occasions, the group takes him as a role model and he is approached for many of
their personal problems. Most of the times, it helps both the staff member and the patient
but sometimes it leads to problems of transference. Female patients get so much attracted
by R's way of handling problems that they often come to him with problems which need
to be checked by the staff to avoid complicated situations.
Yoga Therapy
A very trained and qualified person, a doctor who hails form one of the
neighbouring states, Kerala, gives yoga therapy to the patients. She and her husband work
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for the Theological College and volunteer service to MRC. She is a believer in ayurvedic
medicine and advocates yoga for all kinds of illness. She is a very popular doctor and in a
discussion with her she expressed, "I have immense pleasure in working for the mentally
ill. Though it is very difficult to put them in action, it is very important for them to do
yoga exercises as it helps them in the movement of limbs and muscular flexibility. Most
of the mentally ill, especially the schizophrenics are prone to be inactive, they tend to put
on weight and idleness increases in them. As such yoga exercises help them a great deal
to keep fit. Yoga is very simple to learn, requires no machines or equipments and helps
them to maintain both physical and mental health. While doing yoga, they also learn to
meditate, which has a calming effect on the mind and the body, a basic pre-requisite for
mental health. Yoga therapy has also given significant results among the patients.
Included in it are exercises that which is much wanted for all human beings especially for
the mentally disturbed. Yoga breathing exercises are synchronised with mental and
bodily awareness, which produces 'bursts' of relaxation. The yogic physical postures or
asanas are taught with instructions to be aware of body movements. Finally, there is a
session on relaxation in supine position with eyes closed. These sessions have been
found to have an enormous positive effect on the individuals affected by mental illness
especially the schizophrenics. The disease produces thought disorders and confusions.
Their mind needs rest and relaxation. During yoga, the disoriented thoughts of the
patients are brought to a point of total relaxation.
Thematic Apperception Tests:
Patients are very friendly and most of them speak out their personal problems
without any fear of letting themselves out. Some are very reserved and one can hardly
get any information from them. The Thematic Apperception Test (TAT) demands some
attention from the patients. The value of the TAT exercise is that it helps the introvert
patients to communicate. The case below describes its effect and value.
Case 19
Madan is a very quiet and serious person. He hardly talks. He attracts
attention of the people by one of his acts, which is to stand up frequently from his
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chair and pray. He does it so often that it makes others laugh. But he does not
bother. After his prayers he starts murmuring something which no one can
understand. He does not explain his actions. The staff members keep on
checking him but he never bothers. One day while one staff was sitting with the
ut:lIt:vt:u III ~.Il(1yt:I~. Dt:Wlt: W(111111g lUI (111 (1ll~Wt:1 lit: gUl U~ e1llU 1t:~t:(1Lt:U Lilt:
praying posture and he said he prayed very often as he kept getting prayer calls.
He told him that he hears the temple bell ringing which prompts him to pray. He
often hears voices asking him to pray for peaceful existence. Even during the
sessions, he always gets up and walks out so many times, which creates a lot of
confusion during the sessions. Most of the time he is followed by 3 or 4 patients
and a patient is always sent to bring all of them back. He often gets annoyed if
anyone disturbs him and threatens to beat him up He tends to be very paranoid
and suspects every one. He feels that talkmg to others may be dangerous. During
the sessions, he hardly responds to the counsellors and is always in his own world.
During the TAT exercises, he is forced to respond and that is the only time that
one hears him speak. These sessions help the isolated ones to communicate to
others and be in a group. When the patients communicate the counsellors and
volunteers check their disoriented thoughts.
This test is usually adminIstered to individuals in order to understand their inner
drive and feelings so as to understand the mental status of the individual. During one of
these sessions, the therapist, before starting the therapy briefed them about the test. The
therapist distributed two picture cards to all the patients and asked them to write a story
about anyone of those pictures. Some of the patients were not at all interested; one of
them stood up and left the room. Many more followed. They all had to be brought back
to the room with great difficulty. This is a very common feature during all the sessions.
Based on the picture cards, each one wrote their stories according to their own
imagination. One of them described one of the pictures as that of an earthquake with
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very tragic consequences. Another picture showed a young girl sitting alone. One client
described this as a daughter feeling very sad because her father had passed away.
Another client described this as a daughter feeling very sad and waiting for her father to
have her dinner. These sessions are of value for both the client and the therapist. The
patients feel happy during these sessions and express freely their inner feelings by way of
the story narration. Most of their stories resemble their life events. They narrate their
relationships with family members in the form of these stories. This helps the therapist
and the counsellors to understand the frame of mind of the patients.
During another TAT session, two different pictures are distributed among the
patients. They are given some time to write up a story based on anyone of the pictures
and are later asked to read out the same. Invariably, the two pictures have different
connotation, -one, a happy child playing with the family members and another, a lonely
person sulking. It is interesting to see the choice of picture selected by these patients.
The pictures they select clearly shows the frame of mind they are in. Those who picked
up the card with the happy child, write stories about the happiness of the child, the love
he receives from parents and the joy in the family life. This group of patients obviously
seems more positive towards life and is more cheerful. But those who pick up the other
card write out some depressing stories about loneliness, feelings of being neglected, left
out, life being very cruel to the person because of his unloving mother or father, selfish
brothers etc. These stories strongly link the individuals' inner feelings and it helps in a
great way to understand their frame of mind.
Role oftbe Tberapist
Raju works as the assistant house manager at RMS. He is a middle-aged man.
He is a postgraduate in Sociology, which he completed from France. He has a Diploma
in Special Education and has undergone training in rehabilitation and counselling from
RMS. He has worked for more than five years on problem children. He has been
working for voluntary organizations for the past 12 years on different assignments, e.g.
on physically handicapped children; as a programme manager in rural rehabilitation and
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also worked as administrator-cum-Principal and Counsellor in a leading Institute of
special education for cerebral palsy children. He has a wide experience in working for
the mentally handicapped and the mentally ill. He has been working in RMS for more
than seven years now. He has worked in many places and is well versed in many Indian
and International languages.
Raju was initially working as a Trainee House officer in the organization. During
the time of field visit, he was employed as Ass!. House Manager. During a discussion
with him, he summarised the nature of the patients coming to RMS. He said, "The age
limit of the patients coming for treatment are mostly in the age group of 18-45 years. The
positive symptom exhibited commonly among them is 'recession of illness' and the
negative symptoms are the residual symptoms. It is, therefore, a big challenge and a
serious responsibility for the staff to handle these negative symptoms that playa crucial
role in their bettermenUrelapse. Those who enter the voluntary organizations especially
those working for the mentally ill have to, therefore, be willing to work with dedication.
They must possess minimum insight and perception about the illness in order to work
with the patients".
Raju is an asset to RMS as one can see from his therapeutic sessions, He has a
talent for making the therapies interesting and meaningful to the patients. The patients
are very fond of his sessions and they are totally immersed in these without distraction or
frustration. They are therapeutic in nature and all the patients agree to the fact that his
therapies are very relaxing. One of the patients remarked, "We wait for Raju's sessions as
they always seem to produce a miracle effect in us which nothing else does. After the
therapies, I feel so relaxed, cool and happy, as though the entire burden in my heart has
come down. I also feel free to convey my feelings during the sessions".
According to Raju, these sessions are very important to the staff for many
reasons. He remarked, "Through these sessions, we the staff members come to know
each of the patient's problems, hislher anxieties, apprehensions and ability to cope with
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problems and much more of their personalities. Group therapies help us the most in
understanding them".
Dance Therapy
At RMS, the last day of the week of regular therapy sessions is Friday; it closes
with, the dance therapy. The organization has a very good team of professionals and
volunteers, who are highly talented and capable of producing miraculous results among
the patients as the following description suggests.
Case 20
The dance therapist, Vandhana, is a professional dancer trained in the
classical dance, bharathanatyam. She has done her Masters degree in arts in one
of the American Universities where she has been trained in using arts for
therapeutic purpose. She was very fascinated by the application of dance therapy
among patients. After her return from US, she approached the RMS and
explained to the staff the therapeutic effect of dance on patients with illness and
volunteered to work on the patients. The staff members were very happy and
welcomed her idea.
She involves all the inmates in her well-planned dance movements. These
movements help the inmates in co-ordinating their limb movements. This also
serves as an exercise to the body and a great relaxation to their minds. According
to the therapist, 'dance therapy is a synthesis of physiotherapy and psychotherapy
in which the therapist uses movement interaction as the primary means for
accomplishing therapeutic goals. The dance is accompanied by melodious music
in the background, which is very soothing to the mind. These exercises bring in
them a group spirit, to work with a group and maintain uniformity in the group. It
also removes the fear from the patients as they involve themselves in dancing. It
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gives them great joy to know that each one of them could dance. This therapy is
very effective with individuals who are hospitalised, psychiatric patients and with
emotionally disturbed children'.
Vandhana is a very enthusiastic person and encourages the patients a lot.
Dance therapy does not just aim at teaching the patients dance but it successfully
builds up confidence in them to do something in a group in front of the crowd.
The patients, who are normally shy, come out of their introvert behaviour to
participate in the dance. The dance movements that are made by the therapist are
to be imitated by the patients. This itself is a very good exercise for their brains
and limbs. The effort is to shake off laziness in them and make them do some
activity. Dance movements involve many patterns and following these
movements help in improving their cognitive skills and also improves their
concentration and memory. Once the steps are taught to them they are divided
into groups and made to practice the steps on their own and after sometime the
groups are called to redo what was taught. This is a test for their memory and
retention capacity. The patients have to exert their wills to exhibit their maximum
capacity. After this is over the therapist supports their self-esteem and appreciates
them for their efforts. This brings in them a lot of self-confidence.
After the one hour session, she teaches them the final relaxation technique that
relaxes their minds and their body. Throughout the session she keeps talking to
them in a low and soothing voice to make them get more involved in what they
are doing, correcting those who are having difficulties all against a background of
melodious music. This session is a mind absorbing session and all the patients feel
relaxed and confident after the session.
These therapies have an inherent quality of making the patients get rid of their
complexes and weaknesses, lets them out of their introvert masks and gives relaxation to
their minds which is the most important of all. The angry, the moody, the restless, the
lazy, the shy, the violent all have relaxed minds on the dance floor. This is one of the
185

silent therapies that yields so much positive effect on the patients.
successful therapy and they all wait for the session.
It has been a
Outing
Outing for the residents is an event that is awaited by all. It is a day of joy and
fun. At MRC the patients are taken for outings once a month and at RMS once a week.
At MRF, there is no outing for the patients. When the organization was started, there
were regular outings for the patients but now they have stopped the same.
During one of the outing sessions at RMS, they were all dressed in one of their
best dresses. They had been told to come in bright colours. It was explained to them that
bright colours make one feel happy and cheerful. One of the patients was very good at
singing and one of the assistant house managers too was a very good singer and a good
guitarist. Both of them were ready with their songs to cheer all of them. The following
quotation from the case diary illustrates the excitement among the patients on the day of
outing.
Case 21
On the day of outing, the house manager got ready with his guitar and
started a Boney M song, 'Hooray, Hooray, it's a holi holiday'!' All the residents
were overjoyed and each one of them Wi:\l; ill iht:il Ut:~i UH;~S. Tht:y pialUlt:u auuui
what to do for the day excitedly. They had a vehicle that could acconunodate
about 10. So, it was decided that two trips would be taken to transport all the
residents and the staff. The place decided for the outing by the residents was a
lake close to the half-way home. They preferred it because of its quietness and
the greenery. They packed some sandwiches and some coffee and took some
items for playing like bat, ball etc.,. and started off happily. All of them were
186

asked to sing. The resident house officer was really enthusiastic and encouraged
all the residents to play or dance and be cheerful. They were happily singing
throughout the journey. After reaching the place, initially they were all curious to
look around the place and they just wandered off. Since the place had a water
body nearby, they had to be watched so as not to get into it and get drowned.
Especially because in some cases the excitable ones would get impulsive and
engage in dangerous action.
During the day in the lake, some of them were discussing about the depth
of the lake and what could happen if one falls. These kinds of discussion
sometimes instigate the others to do an impulsive act. Therefore, as far as
possible they were made to involve in some games or some nice discussions about
nature. In spite of all the joyous discussions around some of them were still,
sitting quietly under some tree, one of them staring at the sky. They seemed very
sad and enclosed within themselves, as compared to others who were happily
talking and laughing around.
After sometime, all of them were asked to sit around in a circle and to
suggest some games. The social workers had planned out a nice game of passing
the ball. They had taken a music set and the ball was passed around the circle
while the music was on and once the music stopped, the person who had the ball,
received a small piece of paper on which a request was written, may be to sing a
song or dance or share a joke or any act. The person who got the request slip was
expected to perform the act. One of them got the request to sing a song. But he
was just not prepared to do and the others tried their best to make him respond.
He kept mumbling that he had a bad voice and just could not manage it. He was
somehow made to respond and with a lot of shyness and hesitation he sang quite
well and received a great applause. This boosted the spirit of the other patients
and they also joined in the game. From then on, there was more of happy
involvement by the patients and each one enjoyed thoroughly. Some of them
danced around happily putting on their favourite music shared jokes and played
187

around. On the whole th~ir moods became much better. They were served a
snack of coffee and delicious sandwiches, which they enjoyed. It was a good
break for them away from their usual dining hall and all were happy about the
same. While returning back, they decided to stop in a small sitting place to have a
cup of tea.
The day after the outing they were asked to reflect and speak on the previous
day's outing. Everyone seemed to be happy and gave some suggestions for the next
outing. Some suggested a nice movie, lunch, etc. Some of them teased over each other's
song and dance. All took it sporting except a few who felt hurt and angry because of the
teasing. The staff members cooled their egos. Everyone agreed that it was a different
day and very enjoyable indeed.
Rehabilitation
The major problem that the staff faces is at the stage of rehabilitating the patients.
It is a Herculean task to get employment for the patients, as there is no guarantee that
there will not be a relapse. Even known people who can afford to help simply discard the
ideas of employing them because of their illness. The following case illustration
describes the problems faced by the staff in rehabilitating the patients.
Case 22
A male patient aged 30 years old was taking treatment from MRF. He got
better and showed his willingness to do some work. One of their family members
was running a small candle making unit and the staff requested the family
member to give him an opportunity to do some work. He initially agreed and the
patient went for work. But within a few days he returned to MRF due to
difficulties faced by him in the work place. It was later learnt from the employer
that they could not have him in their unit as he seemed to be a disturbance for
others and work of the unit suffered due to his presence. Though the employer
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was his relative, he got su~pended from his work place. These kinds of incidents
do a lot of harm to the patients rather than helping them. Therefore, rehabilitation
is a very tricky task.
Meera, the Psychiatrist, was very upset with the fact that evaluators of the
organization were more interested to know how many of the patients are rehabilitated by
the organization. She felt that rehabilitation rate of the patients shou1d not be a yardstick
to evaluate the service rendered by the organization. The sponsors also pose this difficult
question whenever they are approached for funds. According to her rehabilitation of
mental patients is so difficult compared to those suffering from other illnesses.
The following illustration narrates what it means for a patient to be rehabilitated
into a normal group.
Case 23
Miss Maria aged 32 years has been suffering from schizophrenia for the
past 15 years and has been under psychiatric treatment. She joined MRC as a
resident two years back. According to the staff members, she was a very quiet
and disciplined girl. She was always kind to other patients and also helpful to the
staff. As a devout Christian, she showed kindness to others. After her stay in the
half-way home, the staff decided to employ her in the organization itself on an
experimental basis. She was good at the secretarial job and was given the job to
assist the administrative office. According to the administrative officer, initially
she showed some fear in dealing with official work probably due to fear of
rejection. But, as time passed by, she showed very good interest at work and
maintained the office in order. But due to her illness and medication, she used to
get tired soon and the staff allowed her to rest during the afternoons. She and her
family members felt very happy that she was settled in some job which would
help her to get over her complexes. Rehabilitation is so important for the patients
as it helps them to regain normalcy. It is very important for the patients and the
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family as it sets a better future for the patient. Maria was very happy that she was
one among the nonnal crowd. She commented, "1 feel so happy to be in the midst
of nonnal people and relieved that I will not be subjected to public teasing and
ridicule" .
Some of the patients, who complete the training programme of MRC, get into
some educational course orjobs. These patients are given accommodation in the hostel.
They are successfully rehabilitated by the organization staff. The following illustration is
a case of one of those who got himself enrolled in a computer course.
Case 24
Mr. Suresh, aged about 19 years old., is one of the hostalites. He goes for a
computer-training course at one of the leading computer educational institutions.
He had fonnal education till twelfth standard. His family lives in the neighbouring
state of Kerala. He has been normal during his childhood. His parents noticed his
illness only when he was in high school. He seemed to behave strangely at school,
picked up fights with his classmates, teachers, etc., and on a few occasions he
attempted to run away from school. His parents received many complaints from
his teachers. At home also he was very restless and often mentioned that he wanted
to run away somewhere, look for a job and live elsewhere. He hated to study. But
in spite of mental problems, he always said he wanted to work and earn money.
His parents initially mistook his behaviour as dismterest in studies. Later on they
took him to a doctor who diagnosed him as schizophrenic. Then he was treated
under a psychiatrist. Once his symptoms were controlled they sought the help of
MRC where he was taken as a resident. From then on the MRC staff took the
responsibility of modifying his behaviour. In a matter of nine months, he became
so much better and less symptomatic that his parents deCided that it was better for
him if he stayed at MRC and therefore, put him in the hostel. From then on he has
been improving a lot under the care and guidance of the MRC staff. He is very
happy with his stay and very eager to earn money after his computer course. He
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expressed his desire to earn

discussions whether they considered these symptoms as those of the mentally ill and if
not what according to them were the symptoms of mental illness.
At the end of a long debated discussion the registers of psychopathology were
listed out by the professionals, namely, -
1. Violence to others
2. Self-destructive behaviour
3. Hallucinations
4. Possessions
5. Isolation
6. Sadness
7. Insomnia
8. Altered talk
9. Bizarre behaviour
10. Fears
11. Feeling of persecution
12. Self neglect
13. Mental deficiency
14. Seizure
15. Alcohol abuse
These were considered to be the most common manifestations of mental disorders
as perceived by the community. During the discussion period one could observe a great
deal of controversy between the professionals on the various indicators of mental illness.
For instance, one of the registers of psychopathology was termed 'bizarre behaviour'.
The debate went on as to what bizarre behaviour would consist of. This was when the
anthropologist and the sociologist carne with very strong points that what is bizarre is
decided by the community and this bizarre behaviour varies from community to
community. Therefore, one should take great care in knowing from the community as to
what actions they consider bizarre and whether they consider these actions as those of the
mentally ill.
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It was also pointed out by the sociologist that many of the symptoms are mainly
related to poverty, for instance, in villages where there was no scope for employment,
most of the people are sad, isolated, suffer from lack of sleep and the men folk somehow
manage to borrow some money and get themselves drunk. Therefore it was pointed out
that many of the symptoms of mental- illness wereare so prominent in many communities
arising out of poverty which should not be mistaken for mental illness. The persons
engaged in identifying the mentally ill through the registers of psychopathology should
be warned to differentiate between those resulting out of poverty and those out of mental
disorder. The team then decided to engage sociologists in the project to bring about
correct information from the community.
The maIn methodology followed In the study was group discussions. The
sociologists made several visits to the villages and conducted group discussions on
mental illness, the problems that those affected by mental illness faced. The villagers
were asked to identify those with mental problems and what they thought about their
behaviour, cause of their problems, remedies, etc. These discussions were all recorded.
Initially, the group was hesitant to talk about the mentally ill. The researcher started the
discussions tactfully illustrating different kinds of problems in the society, asked
questions on evil spirits, ghosts, etc. Then on, the group got interested and started
contributing much information on mental illness. The research group also tried to get
information on the various terms and names used by the community members to describe
the mentally ill. It was very interesting to note that there were many names given to
those who were considered as having mental problems and the names given depended
upon the intensity of their illness. Those individuals with fewer symptoms were
considered very harmless. However, many individuals were identified to be possessed by
evil spirits, ghosts, etc. The reasons for the same were attributed to the occurrence of
unnatural deaths in the village. It was very interesting to observe that many of the
registers of psychopathology as listed out by the professionals were rejected by the
common people. They considered those individuals who refused to go for work and
those who exhibited much laziness and lethargy in activities as affected by mental illness.
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Many symptoms like hallucinations, possessions, altered talk, feeling of persecution,
fears were all attributed to the influence of evil spirits and ghosts.
The behavioural descriptions were presented to the individuals of the community
and then asked to identify whether they were aware of anyone in the community with
these problems.-Dne of the members in the group identified a person in the community
and a discussion took place among the group as to what exactly the problem the
individual faced. The researcher then prompted the group to decide on what the intensity
of his illness was. It was very interesting to observe how the group gave the affected
person a label along the scale of different kinds of mental illness.
As for as remedy to the problems of the affected individual the groups opted to go
to the 'Pujari' who invariably identified it as an ill effect of a spirit, 'dosha'. The family
of the affected individual was asked to perform certain rituals to nullify the evil effect.
The next visit was to the Sorcerer who was considered as an expert to drive away the evil
spirit. If there was no improvement, then they would go to the mosques. When all these
attempts failed they approached the Doctor. In most cases it would be a General
Physician who then referred the case to the Psychiatric Department in the Government
Hospital.
Staff Experience with the Patients
Violence erupts among the patients especially when they experience too much
stress. Once the instructor at Dee experienced violence from a female patient. The
instructor was shocked to get such a response. Later on, she understood the problem and
learned to accommodate to the patients' behaviour. She remarked, 'once an individual
takes up a job as a caretaker for the mentally ill, he/she has to anticipate different kinds of
behaviour. Whenever the patients are restless and frustrated, they are prone to be violent.
Often they are highly suspicious and think that people are harming them'.
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One of the social workers commented that working with the patients is a big
challenge. He observed, 'Violence is not an every day affair. The patients are constantly
observed and if any client is found to be symptomatic, appropriate care and counselling is
given. Every day is filled with anxieties, stress and tension. These problems are part of
the profession and these crises situations help us to learn and understand them more'.
The instructor who monitors the male patients explained that he was very frustrated
with his work. He observed, 'I see the patients improving day by day and also see them
get back home but to see them back with a relapse is so frustrating. That is when I get so
disappointed with the profession. I feel so helpless that whatever efforts were made had
gone to waste. Everything had to be started all over again to get the patient back to
normalcy. This cycle goes on. Though the profession gives much of satisfaction, it is
also equally disturbing and frustrating'.
A Psychiatrist commented 'the area of mental health has so many uncertainties to
work with. Unexpected events occur. In most of the occasions, the patients co-operate.
They desperately need our care and attention. Crisis situation helps us to learn a lot'.
Another social worker felt that work with the patients become easier, when they
co-operate. An instructor observed that each day is a struggle to get the work done by the
patients. It is very difficult to understand their moods and to teach them.
At RMS, the staff members face certain specific problems working with the
patients. Whenever the patients are in a violent mood the staff have a tough task in
getting them back to normalcy. Sometimes this violence is directed only at a particular
staff member and the entire team has to efficiently handle the situation to get the
relationship of the client with the staff member back to the normal. Sometimes when the
patients like the therapist they end up sharing personal problems with the staff member
and as a therapist he cannot go too far in handling the problems. The therapy staff can
thus help the client handle his problem but cannot take full responsibility for solving the
problems in themselves.
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Yet another problem faced by the staff is that of transference. One of the staff
members narrated an instance of transference wherein a female patient got attracted to
one of the male staff. The client frequently had sessions with the staff member. She
liked attending his therapy sessions and this made her attend frequent sessions. This had
to be tactfully handled by the staff so as not to rekindlellny'-episode'- in-the client.
However, this was a very stressful experience for the staff member and also a very
disturbing effect on the client. These kinds of situations are very sensitive for both the
patients and the staff. This has a lot of repercussions on the mental status of the patients
and therefore, requires very effective management from the staff.
Another problem that arises in the organization is that of managing the male and
the female patients. [n one instance, two patients of the opposite sex got attracted to each
other and decided to marry. This is a very tricky problem. Marriage as such is a stressful
event for those affected by mental illness. It is doubly so when both the people involved
are affected by illness. In this case, the staff had a tough time in convincing the two
patients that they cannot marry. The patients underwent lot of mental disturbances and
ultimately the male patient left the organization. This solved the problem to a certain
extent. These kinds of problems often rise in a mental health set up and the staff
members have to be very tactful in dealing with them. The RMS staff members have
been generally successful in solving these problems.
The field of mental health reqUires very skilled persons to treat the patients.
Trained Psychiatrists have to be attached to the organization and this requires a great
amount of money as salary for skilled persons, - so that they may stick to the job.
According to Meera, "Income is not so crucial for me as my husband's income is enough
to run the family. So I can afford to take a low salary. But it is very difficult to get
experienced Psychiatrists since everyone wants to make lot of money and very few are
service minded. She criticises those organizations that run without skilled persons. The
field of mental health requires a resource intensive approach and needs to have qualified
professional staff and has to do away with unskilled workers".
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Conclusion
The three organizations are unique in their patient care. They do have similarities
in their strategies of care and rehabilitation of patients. However, their foci differ. MRF
runs more on a long-term basis in both the areas of day care and rehabilitation. MRC
focuses on a short-term care and rehabilitation. RMS has a combination of both shortterm
and long-term care and the patients have more options. All the three organizations
cater mostly to higher and middle-income groups. Few from the lower sections of the
society do avail their services at a subsidised cost.
The programmes for the patients differ a great deal from one organization to the
other. MRF has a professional staff giving patients psychiatric care and vocational
training by experts in the fields in order for them to be rehabilitated. Every patient is
trained in some working skill that is expected to help him or her in the long run. On the
other hand, MRC concentrates on group therapies to strengthen the survival
communication within the group and living in a group. They believe that communication
therapies can help a great deal to get the sufferers back to their families and lead a normal
routine. RMS focuses more on socIal skills and training that enables the patients in
leading an independent life. The patients learn to be on their own which would help them
to get back to their families and lead an independent life. The therapies at MRF are more
professionally based and their dependence on the volunteers is less. In Contrast, at MRC,
volunteers handle all the sessions. At RMS, the experts in each field handle the therapies
and there is less involvement of psychiatrists and psychologists. Daily routine for the
patients also differs. At MRF, there is less involvement of the patients in the
maintenance of the organization. There is partial involvement of the patients in the
activities of the organization. At RMS;there is total involvement of the patients in all the
activities of the organization. Each one of the organizations has been successful in
achieving their objectives with their different approaches. Families of the patients are
involved in all stages of care and treatment.
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Patient care in the three organizations follows unique patterns, which end in
dIfferent results according to their philosophies. IMRF has been very successful in tenns
of vocational training and long-term rehabilitation. The positive traits of the organization
are the presence of the psychiatrists and professional vocational training instructors
throughout MRC has been very successful in providing short-tenn rehabilitation with its
team of volunteers and a few professionals. RMS has been very successful with its
effective therapies working on the principles of therapeutic community on the lines of
both short-term and long-tenn rehabilitation.
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Appendix.
Voluntary Organisation as an Open System
Input Int. Environment Target Group Output
Psychiatrists Patients Care
Motivation Psychologists Family Treatment
Incentives Social Workers Community - Support
Dedication Sociologists Society Awareness
Technical- Instructors
Education
Administration Staff
Rehabilitation
Supporting Staff
Process of Transformation of the Professionals
Recruitment Output Conflict or Routinous
Individual Orientation Related to the Congruence of Monotonous
Actors
Training
Expectations
Professional
~
~
~ .. Unsatisfied
Set of ideas Modification of of the Ideas Vs. Role
Professional their ideas and Employer
Modified Ideas
Expertise Professions as per Innovative
Expectations
Creative
"Mid,pr! R nip
Appendix
I

Professionalisation of the Mental Health Care Professionals
The psychiatry profession originally dominated mental health care. The approach
was purely uni-disciplinary and gradually it saw the entry of the other professionals.
The psychologists were the earl,)' additions assisting the psychiatrists in psychotherapy
and in application of psychological tools. The later entrant were the social workers who
played a major role in taking case histories, giving more emphasis ion the social
background of the ill individuals. The hospitals have been dealing with the mental illness
problem with this team of professionals. Voluntary organisations have gone some more
forward in recognising the need to incorporate the expertise other professionals such as
sociologists, anthropologists and other therapy experts like those of dance, drama, yoga
etc. This multi-disciplinary approach has proved to be very useful in tackling the
problem of mental illness.
It can be seen that the transition from uni-disciplinary to multi disciplinary
approach has not been a very smooth one. There have been clashes all along. Inn the
three vas selected in the study, it can be seen that one of them has been very successful
in the multi faceted approach and the professionals have been discharging their duties
satisfactorily (RMS). On the other hand there are still problems of professional
supremacy of the psychiatrists in MRF. At RMS, sincere attempts have been made to
integerate the expertise of different professionals. As such one can see that some staff are
unhappy that they are forced to play submissive roles, leading sometimes to frustration.
Definitely, multi disciplinary approach is proving to be very effective in the care of the
mentally ill.

ehal'tl'l" Six
VOLUNTARY ORGANIZATIONS AND PATIENTS' FAMILIES
The mcntal illness is essentially expressed in terms oCthc inuiviuual's inability tl)
objectively assess the interactional situations and respond to it in a socially
understandable manner. This inability affects firstly the individuals' relations with
hislher family members and, in the long nm, the society, in general. The problem of
"stigma" which has been mentioned by most students of the phenomenon, is not only
suffered by the individual but to a considerable extent by the family members as well.
Because of the enormity of the problem (see pages 1,2, Chapter One), the
Government in India is not able to handle many of the crucial aspects of the problem.
Invariably, the voluntary organizations and private clinics have had to step into the
vacuum. The following strategies have been adopted by the voluntary organizations in
involving the family towards the care of the patients.
I. Contact the fami Iy members of the patients and make them aware of the facilities
available for counselling and care.
2. Counsel them on the right approach to deal with the ill member of the family.
3. Supplementing and complementing the facilities provided by the government
organizations.
In India, the mentally ill and their families face lot of problems because of the
social stigma attached to mental illness. The problem of mental illness is understood in
very mysterious and strange terms and most fear about mental illness. Beliefs, myths and
attitudes are so much impinged in the cultural practices of the Indian society. Invariably
most of the families especially the rural families approach astrologers, faith healers,
temple priests to find solution to their wards' problems. Only when they do not see many
results, they approach the professionals. These have a direct impact on identification and
treatment of mental illness. Against this background of ignorance, stigma attached to this
disease and the various magi co-religious beliefs and practices, the Indian society is facing
199

even more a serious problem namely the transition of family structure, which is posing
threats for the care of the mentally ill.
Family has always been the nurturer and caretaker of the individual member in
the Indian society. Linkages between family system and health care are many and there
is empirical evidence to show that at every stage of illness, family plays a crucial role in
understanding the illness, deciding on medical help, coping with the sick member and
caring for them in chronic stages. In a country like India, where there is a shortage of
mental health care facilities, families represent a tremendous resource for the care of the
mentally ill. According to Menon and Shankar (1993), the need for family intervention is
not only to optimise the recovery and functioning of the patients, but also to alleviate the
tremendous burden faced by the families. Many innovative approaches have been
developed by the voluntary organizations in this direction.
Falling sick involves the whole family. It affects the well being of not only of the
patient but also of the whole family by disrupting the normal routine. Depending on the
nature and severity of the sickness, the family is required to mobilise its internal and
external resources to cope with the crisis. Family members can provide physical and
emotional support to facilitate the patient's recovery or perpetuate the illness by their
inability to deal with the illness. Family treatment and care are important factors for
successful coping with many diseases. Kleinman (1981) reports on the basis of a study
conducted in India and China that more than 80 per cent of all sicknesses were managed
within the family and its extended network without resorting to professional help from
outside.
With the change in the family structure and functions, the families of the mentally
ill are seeking for alternatives in providing care for their afflicted family members. Pious
statements about the wonderful Indian family are questioned against the background of
social change in the society.
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Mental illnesses have existed for a very long period and the families and the
communities have coped up with the same. The families do cope up with the burden but
in a country like ours with the prevalence of so many socio-economic problems, taking
care of a sick member poses a strain on the families. Many studies have reported that
there is a heavy burden on the families in taking care of the mentally ill member. Studies
have shown that living in a family environment has a favourable effect on the
improvement of the mentally ill member and also a negative effect if the family
environment is hostile and critical, which lead to relapse in the patient's condition (Brown
and Birley et aI., 1972).
The staff of the voluntary organizations stress on the empowerment of the family.
They work towards the re-integration of the mentally ill member. According to them, the
primary goal of psychosocial rehabilitation in mental health service is the re-integration
of the mentally ill in the community. Therapeutic community approach facilitates by
treating them in a community atmosphere thus helping the mentally ill rebuild their skill
in living in a community (RMS).
The experience of the staff in the mental health field has shown that multiple
therapy that includes drugs, individual therapy, family therapy and occupational therapy.
seemed to bring about more improvement among the mentally ill.
This chapter deals with the changing family system and its impact on the mental
health of its members. It also analyses the role of the families in mental health care and
the ways by which fami lies could be involved in treating the mentally ill persons. In this
regard, the role played by the voluntary organizations in involving the families in
treatment and care of the mentally ill is described.
Changing Family System
"Our society has created the myth of the broken home which is the source of so
many ills and yet the unbroken home which ought to havc broken is an even greater
201

source of tension" (McGregor and Griseld Rowntree-The Family, 1968, cited in Kapur,
1992)
Family life is undergoing periodic changes with the advent of industrialisation,
urbanisation, changing values and norms in the society. The lraditional peasant family
has given way to a modem family style, which, in tum, is paving the way for post modem
family style. This transition of the family system poses new challenges in the field of
Medicine and Sociology.
Shorter (1975) observes, "In contrast with the modem family which emphasised
close affective ties between mother and adolescent children and lifelong companionship
between spouses, the post- modem family is characterised by a diminished parental role
in child care, by the highly eroticised nature (and consequent fragility) of the ties between
the spouses and by the withdrawal of the family unit from generational and community
ties". In contrast with the modem couple, which tended to see the family unit as a larger
social building block, the post-modem couple see marriage as a means for extending their
own self-actualisation.
In India, family has always played a very important role in nurturing its members,
by maintaining intl!r-pl!rsonal rdation between the ml!mbers, facilitating for adequate
interaction among its members, always trying to understand the needs of its members and
helping each member to protect, nurture and rebuild the individual ego. Indian families
are looked upon as units which have role definition, - flexible and compassionate.
The traditIOnal family system with its own norms, ethics, and role definitions
acted as network between members of the society and the needs and urges of the family
members were taken care of. The family system thus knit the society as a whole. Family
has always been relied upon as a therapeutic resource.
In the Indian scenario, there have been tremendous changes in the family system.
The changes started occurring when urbanisation became rampant, giving rise to shifting
202

of families. Many joint families broke up because of jobs available in the cities, leading
to nuclear families. Education had its impact on the families, especially women's
education, which led to many changes in the role of women in the families.
Women, who always played the major role in nurturing the children, are taking up
new roles now, by going out of home for education and jobs. Women have too many
roles to perform, which has led to role conflicts. The effect is on the family, more on the
children, for now these children lack care and love from mothers because of the changing
roles. There is much tension and turmoil in the families of working couples. To ease the
tension, the work previously done by women in the traditional family system, is being
done by others who are paid for jobs like cooking, caring for young ones, etc.
There is now an increase in the number of women gomg out for jobs and increase
in the number of nuclear families which have, in tum, led to the increase in the number of
day care centres for children, hostels, etc. This has led to an increase in marital problems,
youth problems, crime, suicide, and depression among women due to over stress and
among youth due to frustration because of lack of care. Psychiatric problems are on the
increase day by day as the family is gradually losing its grip over the individual member.
The inter-personal relationships between members are gradually changing from
intimate, personal, informal to indifferent, impersonal and formal relations. The marital
harmony is being replaced by marital discords. Happy childhood is being replaced by
unhappy and unmemorable childhood. There IS a lot of frustration among children and
youth because of pent up feelings and emotions unexpressed due to lack of parental care
which is a result of the busy urban way of life, leading to psychiatric problems.
Impact on Mental Health - Evidence from Other Studies
Socially isolated individuals are more likely to become symptomatic or to
somatise. (Shorter 1992). Lipsonki (1987) defines somatisation as "tendency to
experience and communicate psychological distress in the form of somatic symptoms and
203

to seek medical help for them". West (1986) observes that loneliness is linked with
reported feelings of ill health, somatic distress and visits to physicians as well as physical
disease." Patients with interpersonal problems were found to have a significantly great
number of hospital admissions, high rates of surgery and greater rates of visits to the
family physician when compared to controls (Brennan 1981). Stress of coping with
isolation is suspected to produce medical symptoms. The jarred expectations in an
individual's intimate life produces depression, which explains for those couples suffering
from depression because of marital discords. It is also found that wives whose husbands
do not participate in household activities suffered from depression, which explains the
psychiatric problems faced by the present day working women. (Cited in Sawa 1992)
The cause for mental illness is still a debatable topic in psychiatry and it is always
found to be a combination of various causes. The various social causes that lead to
psychiatric problems are unhappy childhood, improper socialization, no proper parental
care, marital discords, separation, divorce, death of an intimate person, trivial life events,
family stress, lack of love and affection, etc.
Thus, apart from other causes the situation in the family acts as a cause to
problems like depression, suicidal tendencies and relapse in patients aillicted from
schizophrenia the most severe form of mental disorders. Hence, it is found very essential
to take the social unit of family seriously and involve them in different phases of mental
health care system.
Family System Theories and Health Care
Various family system theories have treated family as a social unit and addressed
family factors that influence health care from four different perspectives, viz.,
1. Family as a resource for the individual coping with medical illness by serving as the
primary referent and support group for family members of the ill member.
2. Role offamily pathology as a contributing factor in the development of the illness, -
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the 'psychosomatic family' model proposed by Minuchin et. af., (1978) suggests
that characteristics like enmeshment, rigidity, parental over-protection and lack of
conflict resolution in the family produce sickness conditions to the vulnerable sick
member.
3. Family characteristics influence relationship with health care delivery system. The
assumption is that health care systems are themselves fixed entities and variability in
utilization of health care system can be understood as attributable to either individual
or family level characteristics.
4. Family factors as determinants of differential clinical courses and specific illness.
This perspective looks at the role of the differential response patterns of families to
the challenges of acute and chronic illnesses as they influence the subsequent courses
of the illness.
These theoretical perspectives have thus addressed themselves to various issues
like how inclusion of the family unit permits implementation of more effective preventive
measures, issues of diagnosis in the patterns of morbidity and role of the family In
treatment and rehabilitation in chronic cases.
Role of Families in Mental Health Care
A lesson learnt from all family theories is the notion that the isolated individual
devoid of social context, the proto-typical patient in medical training does not exist in
nature. Individuals in all cultures are born into families and most spend their lives
interacting with family members. Even a socially isolated individual can be defined in
terms of lack of supportive family. "We derive from our families of procreation our adult
identities and our primary social support. Every person then is both a unique self and
representative of an intimate social group" (Mead, 1934).
Families are inherent and inevitable participants in the prevention and treatment
of diseases and health problems are commonly viewed as belonging to individuals.
Doherty and Baird (1983) have referred to the therapeutic 'triangle' in all health care, the
notion that family is always a third party to health care encounters between individual
patients and health professionals. Families have found to be the primary source of
205

health-related behaviour patterns, of the critical assessment of individual's health
problems, of the decision to seek medical care, of health beliefs and attitudes influencing
compliance with medical regimes and of social support for chronic health problems.
(Christerseely (1984); Doherty and Campbell (1988); Litman (1974) cited in Sawa, 1992)
Role played by family is very crucial at every stage of the health care system
starting from maintaining the health of the individual members, where various beliefs and
practices are followed to prevent the members from health problems. Its members within
and outside make this possible, where interaction and encounter with the outside world
play an important role.
Family stress also plays a crucial role in the disease onset/relapse of its members.
Many studies have shown that the family stressful events predict physician's visit and
hospitalisation. Family stress precipitates relapse in persons aillicted by chronic disease
such as Schizophrenia following hospitalisation.
Yet another role of family is the role-played in verifying and legitimising an
individual's sickness in explaining why the individual got sick and in deciding whether
medical advice is needed or whether the matter should be handled within the family or by
a family network.
Once the illness is diagnosed, the family response to the illness is very important
in terms of caring and helping the sick member. If the illness is chronic, it calls for
adaptation and re-organization in the family to promote the continued recovery of the
sick person and simultaneously maintain its ability to nurture other family members and
maintain its place in the community. Families' capacity to adapt and re-organize to
facilitate a chronic ill person determines the crucial factor in long term care of the
mentally ill person.
Family processes, relations and memberships influence individual health status in
many ways by means of their Resources and support, health related habits, values and
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eliefs, communication, information filtering, belonging and purpose, moods and
emotions, internal environment, self-sacrifice and co-operation.
Voluntary Organizations' Interrace with the Families
The interaction between the family members and the voluntary organizations
begins from the time the family members approach the organizations for help. The
families which approach the organizations are those, whose wards have been treated or
still being treated in Government hospitals or private clinics. The hospitals and clinics
provide treatment for the patients on short-term basis except in the case of chronic
patients who are taken care on a long-term basis. Once the patients recover from
symptomatic episodes, they are discharged and advised periodical check-ups. It is at this
stage that the family members of the patients find it difficult to manage with their wards.
Their problems are varied.
1. Many find it difficult to understand the illness and its related symptoms.
2. They take for granted that the family ward is totally cured once he has been
discharged from the hospital or clinic as in the case of other illnesses.
3. They get totally stressed out in managing their wards as they continue to face
traumatic situations.
4. They suffer from lack of social network and helplessness in coping with the ill
member.
5. Due to stigma attached to the presence of a mentally ill member in the family, the
families feel let down.
6. They suffer from emotional drain and in some cases economic drain.
Therefore, they look for a professional group that can understand their agony in
coping with the ill member. Their expectations are to get some support in dealing with
the ill member. Their motive is to get temporary relief in taking care of the ill member.
At the same time, they would like to understand more about the problem suffered by the
ill member in order for them to take care of the ill member after his! her short stay in the
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voluntary organizations. Some families which can afford to spend more money do
approach the voluntary organizations for long term care. This involves huge deposits and
therefore, majority opts for short-term care or day care facilities.
Steps Taken by the Voluntary Organizations
L The staff of the voluntary organizations. perfonTI.a.thomugh..study ..on. the patientUJ'--__ _
gomg
through all the medical reports.
2. A meeting is held among the staff members to discuss the cases.
3. Strategies are planned for the treatment of the patients and the families.
5. The family members are first educated on the symptoms of the illness suffered by
their family wards.
5. Coping skills are taught to the families on the ways to deal with their particular wards.
6. Families are involved in the therapies and treatment programmemes.
7. Regular feedback is taken from the patients to assess progress of their wards.
8. The various approaches handled by the organizations towards rehabilitation of the
patients are oriented to the family members.
The voluntary sector has come to the rescue of the families of the mentally ill by
starting half-way homes, creating a therapeutic community where one can help an
individual to remain a social being by taking more responsibility for himself, keeping in
communication all the time. They help the mentally ill person who is cut off from his
natural place in the community, by acting as a therapist in helping him to find his own
place back in the community. Some of the persons who had set out thus to travel from
their home to enter mental hospital may find in the half-way home an opportunity to reconsider
their family and with community's help, care and understanding find its possible
to tum back to their home.
The voluntary organizations are doing admirable work in this field by providing
education about mental illness to the masses, providing care for those afflicted by
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mentally ill at no-profit basis. providing counselling for those afflicted by the illness and
their families, forming social networks of parent groups, self-help groups, following up
the patients treated by them, helping the families to cope up with their wards, educating
them and training them in coping skills, training the afflicted wards in social skills,
vocational skills and in rehabilitating them back in their families, Many are settled in
independent jobs, thanks to the efforts of the altruistic services rendered by these
organizations, Apart from these organizations there are also a few who have tried to
make fast bucks by deceiving the innocent victims of the mental illness
Formal family therapy in India was first started in the three major hospitals in
Amritsar, Vellore and Bangalore, The introduction of the family intervention techniques
brought a positive effect on the attitudes of the families towards the mentally ill and also
made them more informative on mental illness, However, there was a major limitation,
namely, the programmeme could not be replicated in diverse settings and it required the
families to stay in the hospitaL
Family intervention programmemes of the voluntary organizations focus on many
two issues, viz.,
L to Facilitate and optimise the family involvement in the rehabilitative process with the
client and
2, to alleviate the burden faced by the family while caring their ill relative,
According to one of the organization staff, working with the families involves a
three-stage approach and calls for close family-professional interaction where both
assume complementary roles, The first two stages involve planning and the third stage
involves implementation, In the first stage, the resources of the families are understood
viz" the financial resources, the social support enjoyed by the family and emotional
support offered by the family to the patient This helps the staff to understand the coping
skills of the family and plan a programme me accordingly to improve their coping skills
and strategies to cope up with the burden of taking care of the ill member. For instance,
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if the family owns a busine~s
or an enterprise, the staff attempt at rehabilitating the
patient in the family business which would be less stressful to the patient.
The second stage involves a hierarchy of interventions to be chosen for instance;
there may be many factors involved, these could be a) patient, b) family or c) service
delivery related. These factors playa great role in deciding the form of intervention to be
given to the families. Patient-related factors pertain to the condition of the patient. The
interventions planned for the families should clearly be specific to the patient's conditions
and hence, the symptoms of the patients have to be understood. For instance, the
intervention module for a family with a patient suffering from delusion or hallucination is
different from one suffering from suicidal tendencies or one who is very inactive and
dull. So, the patient's symptoms have to be understood.
Similarly, families also differ in varying degrees in terms of education and
economic status and the attitudes towards the patients. The module differs accordingly,
for instance, a family with education could be dealt with written material whereas the
family with no education has to be dealt with in an oral fashion and needs to be
constantly educated informally whenever the family visits. A supportive family that
understands the situation of the patient needs to be given psycho-education whereas a
critical family needs in-depth intervention with more information about the illness and
also needs to be involved in a relatives group or self help groups where the families meet
and share their burden. Lastly any intervention programme needs two vital factors, viz.,
time and personnel to implement the modules and to get good results out of the same.
The stage three involves the implementation of the modules of intervention.
These intervention modules used by the organization are innovative and exploratory in
nature and modifications and improvements are taking place with more experience in this
field The major stress by the organization is on giving information to the families about
the illness of the family member, - psycho-education.
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Psycho-education is the basic step to any intervention programme and this is done
both in structured and unstructured manner. The structured family duration
programmeme represents one modality in information dissemination and is offered to
families who have at least qualified secondary level of schooling. The organization
conductsthisprogrammeme on one day involving about ten families. The programmeme
is a multidisciplinary educational programmeme involving three aspects of the illness and
is handled by a three-member team consisting of Psychologist, Psychiatrist and the Social
Worker. The format of presentation is both didactic and interactive with extensive use of
audio visual aids. Families are encouraged to share their experiences in coping with the
patients and successes and failures faced by them in dealing with their members.
In the first module, the Psychologist deals with the signs and symptoms and to
made to understand the case histories of the members of the families by discussing the
meaning of the symptoms. This helps the families to empathise with the patient's
conditions. The second module is taken up by the Psychiatrist, which involves the
aetiology and an overview on management issues. The families are expected to share the
problems faced by them by managing their wards. The importance of strictly following
the medicinal regime is stressed, besides the need to control one's own behaviour
responses to avoid aggravation of the patients' behaviour. The third module explains the
concept of rehabilitation and is handled by the Social worker where the positive role of
the families is stressed.
The staff of the organization reacted to the family education programme thus.
According to them,
1. the families have to be educated frequently and systematically, as the families do not
retain the knowledge gained for a long time;
2. families welcome these educational programmes and are enthusiastic in sharing
their problems and experiences;
3. professional staff gains lot of input about the family coping skills during the course of
interaction;
4. during these sessions families seek help from the professional on various problem
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areas; and 5. these programmes serve to sensitise the families to involve in depth
intervention.
All the staff agreed that this could be implemented only in those families with at
least basic secondary school education. Those with no basic education had to be dealt
only by non-structured family education programme which is imparted by the following
ways VIZ:
L non-fonnal discussions with families, single or in-group;
2. use of audio-visual and electronic media to educate the family members; and
3. use of charts, pamphlets and booklets as educational materials.
These non-structured programmes are aimed at problem solving and enhancement
of coping strategies. As problem-solving is based on the attitudes and attributes of the
patient's behaviour held by the family, this is taken mto consideration in developing the
module.
Problem-solving approach involves handling in different stages. Initially the
problem and the objective or goal is defined and then redefined and sub optimal goals are
identified. Then the group identifies strategies for each sub-optimal goal and these
strategies are reviewed and refonnulated. The families are explained in detail about
solving their problems by illustrating life experiences. These help the families to deal
with problems and crises situation.
Another approach used by the organizations to solve the problems is through
relatives' groups, wherein six to seven families are invited to share their problems with
each other. The experiences of the families, successes and failures, are shared and
discussed by which the families learn the pros and cons of different situations and how to
handle the same. Yet another approach is through therapeutic dramatics or role playing
wherein the staff and volunteers of the organization take up different roles of the family
members and the role of the patient and enact day-to-day life situations projecting the
problems and difficulties faced by the family members. They also depict the difficulties
faced by the family members and offer suggestions to solve problems. The message
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delivered by these plays is that any kind of undesirable behaviour of the patients could be
corrected with the right approach.
Support activities are yet another form of intervention programme offered to
families. These support activities are of three kinds, viz.,
l. child support, wherein the children of the mentally ill are given financial support
in education by way of buying books, paying fees, etc;
2. formation of self-help groups, which enables the families to get together, interact
and share their problems with each other. This serves as learning experience for
the families attending the session;
3. referral to other social welfare agencies, The organization refers the mentally ill
individual or one of the family members to other welfare agencies for seeking
employment which would help the families to improve financially.
The voluntary organizations have fully realized the importance of the
involvements of the families in all stages of treatment and rehabilitation of the mentally
ill. Family sessions and family therapy help in a long way to understand the problems of
the afflicted individual. Family therapy is found to have remarkable effects on relapse
rates and rehabilitation among the schizophrenics. Family therapy involves psychoeducation,
aiming at: I. providing adequate information to the family members;.2.
improving the coping skills of the family; 3. expanding the social network of patient and
hislher family; and 4. establishing empathic interaction with family members in dealing
with the problems.
Psycho-educational interventions play a great role in providing adequate
information to the family, enhancing coping skills and increasing their social network and
multiple family groups. Many therapies like family crisis therapy, individual support
therapy, relatives group therapy, behavioural family management, family psychoeducation,
psycho-educational multiple family group are now prominent therapies which
have for their target the social unit of their families.
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Family Interventions
Families coping with patients afflicted by psychiatric disorders especially
schizophrenia are faced with many problems. First of all there is lack of knowledge
regarding mental illnesses, which delays the identification of the illness in the patients.
There is a great delay in approaching for medical help. This. problem is applicable to all
socio-economic classes irrespective of educational levels of the families. In the lower
socio-economic classes, where there is lack of network, lack of correct information, the
problem of identification of the problem is more severe.
Family Counselling and Psycho-education
Counselling and psycho-education help a great deal in solving many problems
suffered by the mentally ill and their families. The following case illustration explains
how the intervention of the organization staff through counselling and psycho-education
helped the family members to accept their ward's condition, helped in providing social
support for the patient and thus, prevented relapse.
ease2S
Malini belongs to a high-income group. She has been a very loved child
during her childhood. The family members noted drastic changes in her after her
mother gave birth to a baby son. The changes in her were taken more as a feeling
of depression due to the presence of the new born. Seldom did the family
members suspect any mental illness. They took her reaction to be very normal.
But her condition during her childhood disturbed the parents. She had the
tendency to go around young boys, get involved in love affairs. The family
members did not take her behaviour to be anything serious or problematic. They
did not approach any doctor or a Psychiatrist. According to the family members,
the symptoms exhibited by Malini did not suggest that she could be suffering
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from any kind of mental illness. The parents did not suspect the same. In most of
the cases, these kinds of mental and emotional disturbances are taken for granted
by the family members and as such medical help is delayed. Thus, the delay in
identification creates a delay in treatment and hence, a delay in recovery. The
problem is recognized as a problem only when it attains severity, for instance, in
the above case, Malini after an episode of being cheated by her lover, tried to
harm herself by cutting with a blade and also tried to end her life by hanging.
This was when the parents took her to a Psychiatrist. He diagnosed her to be
schizophrenic and as suffering from the disease for many years.
Schizophrenia is a very threatening, confusing and unpredictable illness. The
family members are mostly unaware of symptoms of this illness and most often mistake
certain symptoms to personality defects or character traits. They are unaware of the
extent and causes of the mental disruption and aberrations that are besieging their ill
relative. To the families, diagnosis and treatment often appear mysterious and sometimes
arbitrary and erratic. They feel uninformed and unguided by clinicians. All these are a
result oflack of knowledge and myths about the mental illness.
In the above case, the family members have had a long struggle of admission and
re-admission in hospital wards. In order to find a more practIcal solution to the problem,
they approached RMS. Since the family belonged to a highly educated class, the
therapeutic community staff at RMS found fewer problems in talking to the family
members. But since the family had a highly sophisticated background, it had other
typical problems of a very rich family. The patient's closest family members were her
brother and a paternal aunt. She lost her parents at a very young age. The staff identified
the problem faced by the family. They felt the family lacked a social network and the
patient needed social support.
The staff felt that the major problem the patient suffered was loneliness as she
was forced to live alone in a house. Her brother was married and settled in a different
place. He was in the navy and was on constant travel. The loneliness suffered by the
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patient led to depression, self-destruction and suicidal tendencies. Therefore, the patient
suffered frequent relapses. The organization staff felt that the major strategy to be
adopted in this case was to talk to the closest family members and build a social support
base for the patient.
The brother and aunt who was the 10caLguardian were called to theorganization....
for discussion. The staff found that the brother was not in a position to take care of the
patient, except that he was prepared to shell out money. The aunt categorically declared
that she couldn't take care of her niece on a long-tenn basis as she felt she was under
risk. The staff had to explain to the families that the patient was very vulnerable to their
attitudes towards her.· She deserved more care and love in order to get rid of her
depression and loneliness. The family members were made to understand that their
attitudes towards the patient detennined to a great extent her recovery or relapse. They
were made to realise that giving money and luxury were not enough for her to take care
of herself. What she wanted was a supportive family to reduce her problems of
depression and loneliness.
The family members were invited frequently for counselling and education. They
were made to sit through the therapy sessions in order to understand the patient's
behaviour. After the sessions the family members' feedback was taken and the staff and
the family members held discussions about the case. In the process, the family members
felt clearer about the patient's condition and offered support to her. Since they could
afford the money they decided to put her on a long-tenn basis with the organization. The
organization made it certain that the family members would offer social and moral
support to the patient apart from financial support.
This is how the staff integrated the patient and the family members by educating
and counselling the family members to accept the patient's condition and offer support.
The staff transformed the family members from a tendency of abandoning the patient to
acceptance of the patient. This not only helped the family members but also the patient
to find a permanent solution.
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Involvement of the Families in Family Support Groups
Family support groups help the afflicted families to bring out their problems in a
group and find solutions for the same through the experiences of other families in the
group. Family support groups are very effective in educating the family members on the
symptoms of the illness suffered by their wards and coping skills-required to deal with
the afflicted member.
Case 26
Kamala belonged to a middle class family and was always a very softnatured
person and light-hearted, never took studies seriously. She was a very
pampered child by her parents and brothers. They had lot of property and spent
lot of money on her. She was very well cared for and she was a spoilt kid.
During her adolescent age, her mother noticed some odd behaviours like being
sexually perverted, reading books on sex. Her mother was a little ashamed and
shocked to talk about this to the other family members or to doctors. In her early
twenties, she was shown to a physician who referred her to a psychiatrist. The
family members felt very scared to go to a psychiatrist, as they feared about the
consequences. So, they decided to marry her off spending a lot of money, so that
her problem would get solved. But unfortunately, they got worsened. Ultimately,
the marriage got nullified as the court decided her unfit for married life as she was
suffering from schizophrenia. The family members felt that the clinicians did not
advise them and they felt so uninformed about the symptoms of the disease. They
felt that if guided properly, they could have avoided marriage of their daughter.
The marriage created more problems for Kamala and led her to many suicidal
attempts, worsening her situation. The family members expressed that they felt so
uninformed and their lack of knowledge about the disease delayed medical help
and they felt guilty for bringing ruin to their own child.
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In this case, the family was asked to attend family support group consisting of
many families suffering from the problem of coping wit a mentally ill member. This
group helps families in many ways to understand and accept the problem of mental
illness.
The problem in this case was that the family members did not understand the
problem suffered by their ward. They were not uninformed about the symptoms suffered
by the ward. Neither were they aware of the course of treatment and care to be adopted
in order to cope with her illness.
The staff of the MRe made the family members understand that their ward was
suffering from mental illness. The family members found it really hard to accept the fact.
They held that their daughter's failure in marriage was due to her husband and her inlaws.
They could never accept the fact that their daughter suffered from an illness that
did not enable her to be a success in the institution of marriage.
Therefore, the family members were asked to attend family support groups,
wherein some family members faced similar situation. An interaction with them made
the family members realise the complexity of the problem faced by their ward. In these
kinds of cases the staff explain to the family members different cases suffering from
mental illness and the symptoms suffered by them. In many cases, the symptoms are
hardly notices until a crisis occurs. Giving various instances, the staff make the family
members understand the problem. Being in a group gives the family members a sense of
belonging to a group suffering from similar problems. Otherwise, they feel so lonely and
left out and sulk within themselves.
In the family groups, each family member expresses its views and problems.
They discuss various methods and strategies to cope with the difficult situations. The
staff encourage them to let out their feelings. They offer various suggestions to
overcome suffering. Discussion in a group gives lot of freedom and ventilation tot he
family members to express freely their problems.
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This strategy helps the stalT and the family members to tadle the probkm easIly
The family members expressed the feelmgs better In a family group than among the stalT
The family members expressed that they got lot of consolation bemg In the group. They
felt easy to exchange then problems and found It useful when other members dIscussed
various strategies of dealing with their ill wards.
Since the staff members are also present in the group, they get instant suggestIons
in coping with the problems. The family members leave the group sessions with a
relieved feeling that they are not the lone sufferers of the problem but one In many. The\
feel much better that there is help around them. These groups are a great success and
they fulfil the need for a social network for the Isolated families m need of help
Self-Help Groups to Build Social Network and Overcome Problems of Social Stigma
Social stigma attached to mental illness poses a huge obstacle to the families to
approach help from their kith and kin. They fear socIal rejection and hence cut down
their social network, which hinders them in providing care for the III member. SocIal
stigma on mental illness is so strong that support and empathy is lacking for those
suffering from mental illness unlike those suffering from physical Illness
groups help the families to build a supportive social network.
Self-help
Case 27
Kannan was a middle-aged man hailing from a middle class family. He
was qualified in Technical education and got a job as a factory worker. He had
been doing very well at his job. He had lot of friends and has always been a
sought after person by his fnends. At home front, he was never known to be
problematic except that he used to talk a lot on various topics. He was married
and had children. His problems suddenly started showing up at work. His boss
complained that he was not working properly and he seemed to avoid work. He
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just whiled away time The factory medical department gave him medical help
and counselling. The family was called to discuss his problem. The family
members were shocked to hear from the factory workers that he has not been
behaving normally. When questioned by the doctors and family members about
his change, he simply said he has been told by some voice not to work and to
concentrate on worship especially to reptiles and birds. The medical team
referred him to a Psychiatric hospital and he was diagnosed as schizophrenic and
given medication and treatment. His condition got worsened. He refused to go to
work. He fought with all his friends. He was very problematic to manage at
home. His wife and mother were the worst afflicted as he was very violent
towards them. He refused to cooperate with them, did not take regular
medication, showed irregular food habits. He would always lock himself up in a
room to worship. The family members could not manage him and they felt very
stressed out and ashamed by his behaviour. They complained of emotional drain.
They cut down on their social relationship as they felt that others were looking
down upon them and they hardly asked for any help from their kith and kin.
Their only help was from the doctors. But at home they faced dejection managing
the ward. They complained that they hardly got any help from their neighbours
and relatives. Everybody feared to come near Kannan. The family members
expressed that it was a curse that their ward was suffering from a mental illness,
which has strong social stigma, and people hardly come forward to help.
In the above case, the family members suffered to a great extent because of the
;tigma attached to mental illness. The respect and the prestige the family enjoyed
;uffered rejection from their relatives, neighbours and friends. They got their ward
treated in a Government hospital. An admission and discharge from the hospital made
things worse for the family members. Their social network suffered. They had no one
visiting them and the worst hit were the ward's wife and mother. The children of the
ward also felt ashamed to mix with the other children.
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Though they got medical supelVision in the hospital, they still felt uncared for and
outcaste. They approached RMS for help. The RMS staff gave them psycho education
and family counselling to start with. Since they were in a position to grasp written
materials, they gave them some reading material on mental illness and symptoms. The
atmosphere in the organization made them feel more comfortable. They were asked to sit
through various therapy sessions, which attempt at improving the behaviour of their
afflicted individual.
The family members were counselled by the experts on the course of action to be
taken to deal with the individual. Instead of sulking within four walls of their house, they
were encouraged to participate in self-help groups to understand and tackle their
problems better. The problem, which seemed so confusing and threatening to them
looked much simpler and easier after attending family sessions at RMS.
During these family sessions, the staff ensure that the families feel cared for. The
staff spend lot of time with the members patiently and listen to their problems and
complaints. In this case, the family was totally isolated from family network and as such
most of their feelings were bottled up in them putting them in frustration. The staff
rightly tackled this during their therapy session. The end result was a better-equipped
family to heal with ups and down of their ward's illness. The staff's attempt in helping
the family members and their patients during the course of stay helps in a long way in the
care of he mentally ill patient.
Family Counselling to Reduce tbe Burden and Improve Coping Skills
Family members face a lot of burden taking care of the afflicted individual and
some of them translate their complaints into outright rejection and abandonment. In the
traditional families and peasant families, the family members take more responsibilities
for their afflicted family member than those urban counterparts who are caught amidst
the busy urban way oflife where indifferent and formal relations exist between the family
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members. Family counselling helps the families to reduce their burden and also offer
solutions to their problems.
Case 28
Raghu hails from a middle class family. From his childhood he has been
exhibiting problematic behaviour like teasing girls, beating his sisters, quarrelling
with his parents, .. etc.He nelleLshowed...interestin llisstudies .. His mother bad ..
serious health problem when he was 14 years old and she expired. He was the
eldest in his family and he had two sisters and a brother. His father was forced to
marry again by his family members in order to take care of these children. Raghu
was very upset by this marriage and always created problems for his stepmother.
She gave birth to two children and Raghu always showed his hatred towards
them. On his father's retirement from service, he was offered a job in his father's
Company. He was doing well in his job and suddenly he exhibited lot of
violence, irrelevant talk, suicidal behaviour that worried his employer and the
family and he was advised to take rest. The family members took him to a
psychiatrist who advised medication and hospitalisation. He was admitted in the
hospital and returned home after a long stay. His return caused more problems to
his brothers and sisters as he started beating them, which put everybody in
trouble. The family members tried their level best to cope up with him. But the
daughters-in-laws and sons-in-laws of the family totally rejected him as they felt
he was harming the family prestige. The family members thus decided to leave
him in a long term cares rehabilitation home. This is a typical case of rejection by
the family after lot of humiliation from their social circle. They ultimately decide
to abandon the ward in a home for long-term care.
Most family members complain of economic drain, emotional drain, lack of sleep,
depression, tension, interferences with daily life and fear of unpredictable behaviour and
difficulties in communication and strained family and marital relationships. Some resent
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for having become captives of the situation and also are beset by feelings of guilt,
inadequacy and anger.
In this case, the aillicted family member has been under treatment in psychiatric
hospital. He has been subjected to shock therapies, frequent admission and discharges
from hospital. The family members tried their best to cope with his illness ..... But.he-was
totally unmanageable as they suffered verbal abuse and violence from him. Since they
lived in a joint family, the daughters-in-Iaws of the house often quarrelled with the
afflicted member's mother, which created lot of problems.
Finally, the parents approached MRF for help. They felt medical treatment in the
hospitals alone did not solve their problems. They came to the organization to put an end
to their trawna suffered because of the mentally ill member. The staff held discussions
with the parents of the ill members. They expressed that they could not manage the ward.
Since they were old and dependent on their other son, they were forced to seek
alternatives for care of the ill members. The staff felt that the parents needed counselling
as they were so broken down. They were emotionally drained.
Counselling helped the parents a lot as they felt that there were some alternatives
available in the voluntary organizations to take care of their son. They felt very ashamed
that their own family members were rejecting their son. The staff helped the parents to
reconcile themselves. They planned a suitable shot term programme for the ill member,
so that the parents are temporarily relieved of the problem.
This was a typical case of a rigid family where the acceptance of the afflicted
family member found lot of difficulties. Though the parents were willing to take care of
the ill member, the other family members totally rejected the same. So, the staff
suggested that the family members to let the patient attend day care and in future they can
think of long-term rehabilitation. The family accepted the offer and the member was
ultimately given to the custody of the organization on a long-term basis after a few years.
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The staff thus solved the trauma faced by the members by their intervention
through counselling, day care and long-term rehabilitation.
Community Based Rehabilitation
In contrast to the urban areas, in the rural areas where the social network of family
is still intact, the family members decide to take full responsibility of the wards in spite of
the consequences. They complain -of economic drain; spending"lot of money on doctors
and medicines but not of emotional drain. The organization staff encourage the
supportive families to take care of their aftlicted wards. The ultimate aim of care for the
mentally ill is to find solace in their families and communities.
Case 29
Shankar belongs to a rural family. His parents are farmers with minimum
landholdings. Shankar has always been a problematic child to them refusing to
study and work. This annoyed his parents initially as he would not participate in
any of the family affairs, keep a distance, hardly had any friends. He was always
depressed. But he was very pious and used to spend all his time in the temple.
Everybody in the village was sympathetic towards him. He was harmful to others
only when they criticized him. If left to himself he was very well behaved. He
showed violence to people who teased him. He would refuse to work and chose
to be idle always. This annoyed his family members. During a medical camp in
the village, the doctors advised the family members to take him to a psychiatric
hospital. The family members were shocked initially to know that their ward
could be suffering from a mental problem. They initially refused to treat him.
But later with a hope of getting him to normalcy, they approached the
psychiatrist, who advised medication and to be prepared for his condition to get
worse. The family members were very upset but they took it as a challenge to
take good care of him. The family members never took him as a burden and the
villagers also cooperated a lot and they did their best for him. Though Shankar
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continued to be the same, he received love and warmth from the villages and he
was never ill treated or rejected by others. This is a typical instance of a family
cushioning that is so important in the care of the mentally ill. Unlike, the urban
set up where each individual is busy with his own priorities in life and hardly
cares for the afflicted person. They treat the afflicted individual as burden and
many pray that his end should come soon, as it would solve all their problems.
But in a rural set up, where life is much simpler, the family members and the
social circle take care to see that the individual is able to continue in the present
state without any problems. This is the best contribution that a family and
community can do towards care of the mentally ill, to put up with his adverse
behaviours and care for him.
This is a typical case of an ideal situation where the family and community bore
the burden of taking care of the sick members. MRF ran community based rehabilitation
in a rural area. The staff observed that the families of the mentally ill member were not
so traumatised as their urban counterparts. In these cases, the staff of the organization
held camps for the families, encouraging them in the effort in taking care of the
individual. The families did come up with problems and the staff offered them
counselling in dealing with the problems.
Rehabilitation of the mentally ill is the ultimate goal of all those working in the
field of mental health care. The ideal solution to this problem by the MRF staff in the
rural areas helps many patients find solace within their own community itself thus
preventing neglect by their own family members.
The rural families, most of them poor, find that care for the mentally ill member is
cheaper and simpler at home than leaving them under long term care in the organization.
The staff focus on psycho-education and counselling to the families in order to cope up
with the family member. This has been highly successful as the rural families rarely
approach the organization for long-term rehabilitation.
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Involvement Of Families in Groups to Reduce Their Hostilities and Expressed
Emotions
In most cases, the stress of caring for the chronically mentally ill leads to
depression and anxiety, which leads to diminished capacity to manage the illness
successfully, especially when unsupported by professional treatment system.
Case 30
Sowmya belongs to a very-pathological family. She was suffering from
mental illness. She suffered from polio attack during her childhood that has
paralysed her limbs. With her physical handicap she managed to study and was
known to be brilliant in her classes. After school, her family members tried to get
her a job of her grandfather's after his retirement by showing false papers that she
was his youngest daughter. This annoyed her and she started behaving very
hostile to her family members. Her father was always a problematic person as he
was an alcoholic from his young age and Sowmya has been a victim for all his
verbal and physical abuses. This always upset Sowmya and she tried to escape
from the house many times. The family members were critical towards her and
always showed resent to her actions. Her mother unable to tolerate the sufferings
from her husband left the other two younger children under the care of Sowmya
and let for abroad as domestic help. This brought more burdens to Sowmya and
she started hating her parents and abused them often. She was left with her aunt
who suffered many problems dealing with her. She ended up ultimately with
depression and had to be treated by the doctor. Her aunt felt so victimized by the
whole situation. She suffered from stress and could no more tackle the situation.
She suffered criticism from her husband for bringing her mentally ill niece into
the family. This led to more tensions in the family and the family members felt so
helplessly caught in the situation.
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Expressed emotion in the family namely the critical views of the patient
by the family members and over-involvement, i.e. highly protective in nature has
an impact on relapse of the illness. When the levels of expressed emotion is high,
relapse would occur more frequently. The relapse is found to be more in isolated
families. The reasons may be due to small social network, lackofhelp-andadvi~resulting
in frustration of the family members leading to expressed emotions by
way of criticizing the mentally ill member.
This was a typical case of a critical family. They felt over-burdened and
emotionally drained taking care of the ill member. In their frustration, they were very
harsh and rude to the ill member, resulting in negative consequences.
The staff identified that the family was hardly any supportive family. Therefore,
they engaged them in a relatives' group, self help group to meet other families. This
made them realise that their efforts in caring for the ill member was very minimal and
also learnt that there were better ways of handling the problem. Intervention through a
group is much smoother for the staff rather than attempting to change the attitudes of the
family members by the staff themselves.
Exchange of views is much easier in a group, a homogenous group of families
suffering from a similar problem. The affiicted family felt trapped in a situation but once
in a group they felt better to know that there were many more caught up in the trap like
them. The staff helped the family members to gradually change their critical views about
the patient towards more sympathetic and supportive views. The families felt happier in
the organization as they realised that there were many who sere waiting to help them
from day to day problems, in contrast to the Governmental organizations where beyond
medical treatment permanent support group is lacking. Self help groups and relatives
groups thus helped the family to get over their blues and continue their care for the ill
member more supportively.
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Counselling to Improve Coping Skills
Counselling proves to be a simple solution to many problems. Th following case
illustrates the efforts of the VO in bringing betterment to the patient through family
counselling.
Case 31
Sukanya hails from a high-income family with lot of property. She lived
in a village when she was young and after marriage settled in a town. She has· .....
always been a pampered child and got what she wanted. Her parents were
affectionate to her as she was the only daughter. She had four brothers, well
educated and settled in United States.
During her childhood she was an adamant child and always demanded that
everything should be her way. Except for that the parents did not notice any
behavioural problems in her. However, her mother complained that she was a
very stubborn child, refused to go for studies, spent lavishly and when questioned
reacted very violently. But her parents did not take these as behavioural
problems. After marriage, she did not change her nature and she faced lot of
problems in her in-laws family. It was ajoint family and she was not at all happy
there. She felt overstressed and could not manage herself. She was quarrelsome
with everyone. She even beat her husband. She tried to commit suicide twice.
Her husband decided to leave her in her mother's place. After that he filed a
divorce. On mutual grounds, they got divorced.
Marriage gave her lot of stress and her conditions worsened. Her mother
expressed that Su went totally out of her mind; she abused all her family
members. Her verbal abuses were very hurting to others. Her husband showed
her to psychiatrist immediately after marriage and she was told that she had
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mental illness. She was advised medication. Her brother helped her a lot by
sending medicines from abroad.
Her parents suffered a lot, as they had no professional support in their
hometown. They felt very depressed to manage her. They felt that all their
potential of tolerance had gone and they were left with no strength to take care of
her. They longed for professional help to get relieved -[mIll the stIess of l:"oping:m_ ... m.
According to her parents, they felt very lucky for being one among the few who
got accommodated in a professional halfway home.
The question of long-term care of these mentally ill is under jeopardy. In most of
the cases it is the parents of the mentally ill irrespective of their age who take care of
them. Once the parents reach old age, the plight of these mentally ill member is very
pathetic. The siblings of the ill member invariably are in a very delicate situation to take
the responsibility of caring because in most cases they are married and so it is dependent
on the acceptance of the presence of the ill member by their wivesfhusbands and their
families. It becomes a very difficult task of the family members to decide the future of
these mentally ill members. The modem urban family is so dominant with selfish
motives, indifferent and informal relations that many are desperately looking for
alternatives for their wards.
This was another case of helpless old parents, who had enough money to take care
but much less emotional strength to face the problems associated with mental illness.
These families approach these organizations seeking for long term care for their wards.
But the organization staff are very cautious not to accept the family members' proposal
unless they find it very genuine.
First of all the staff assess their sources and abilities, try psycho education and
counselling, explaining to them the various strategies for coping the mentally ill. In this
case, the parents were very cooperative and agreed to try the short-term rehabilitation
programme. The family was called frequently and involved in various sessions to make
229

them understand the strategies to be adopted in taking care of the ill member. The patient
was sent home every three months home for assessing their behaviour at home to see if
any progress is made. There was a definite progress at the end of the rehabilitation
programme. However, the parents opted for long-term rehabilitation as they felt they
were too old to take care of her in the right manner and requested for long-term
rehabilitation. Henceforth, the staff took the ward in for long-term rehabilitation.
In-depth Intervention to Change the Attitudes of the Family Members
In some cases, the families require in- depth intervention especially so when they
are very hostile to the patient's condition. The following case ia an illustration of how
the VO dealt with a very critical family.
Case 32
Usha has always been a very depressed person right form her childhood.
She hails from a lower middle class family. Her father is a drunkard and he often
beats his wife and children. He has been in this state right from his adulthood.
He is an alcoholic. His parents have suffered a lot because of his alcohol
dependence. They married him off thinking he would get better if given more
responsibilities in life. But it all worked against their wishes. His daughter Usha
was the worst affiicted. Her father abused her often. She was always depressed
thinking of her situation. This led to suicidal feelings and she tried to kill herself
many times. Her mother, unable to bear the torture of her husband went abroad
for doing domestic labour and Usha was left alone to manage her alcoholic father
and her younger brother and sister who was just two years old. Thus, the family
responsibility frustrated her a lot and she often went out of the house and tried to
end her life. She was admitted to the hospital many times, given medication and
counselling.
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Her family members especially, her aunt who took care of her and her
siblings was very critical about her behaviour. She showed her disapproval very
often. This aggravated Usha more and more. The family members in their
inability to manage the ward, Showed their frustration openly. This expressed
emotion of the family members acts in a negative manner towards treatment and
care of the afflicted family members. Therefore the individual suffers relapse
caused due to the criticisms made by the family members.
Incidentally, their relatives isolated the family. Most of them were scared
to have any link with them as they suffered from too many problems, financial
and emotional. They feared the presence of a drunkard father and a mentally ill
daughter. They opted to keep away from them. As such their social network was
almost niL The family members suffered emotionally due to the indifferent
attitude of the kith and kin. They were very frustrated and were unable to cope up
with the situation. The emotional drain combined with a fractured social network
worsened the situation and the family instead of helping their aftlicted ward,
brought more disturbances to the afflicted ward.
This was again a case of a highly critical family They had to be dealt with indepth
intervention. The family members were briefed with the symptoms of the illness.
They were provided with reading materials to understand the seriousness of the illness
suffered.
The family members were initially very adamant to accept any advice as they felt
they have done enough for the sick member. They denied that the sick member suffered
relapse due to their wrong way of handling the situation. The staff members met the
family members at home; involving them in long counselling sessions, making them
understand the condition of the patients.
The family needed counselling and involvement in groups. They were asked to
attend the self-help groups. Initially, they showed reluctance but with more exposure to
231

the groups, they became more interested and this helped them a lot. The therapeutic
community staff at RMS, attempted at changing the attitudes of the family members
towards the mentally ill. The hostile attitudes of the family members got transformed
into more supportive views.
The staff had great problems in dealing with the case as they had to counsel her
drunken father who invariably did not attend any of the family sessions. The aunt
refused to respond to any of their intervention strategies as she felt she was not
responsible for the ward. She had lot of complaints over the ward's parents and felt that
she was forced into taking care of the ill member. The toughest task for the staff was to
convince the family members to get involved into self-help groups. In this case, the aunt
who was the guardian was very adamant to get involved in groups. However after a long
counselling she took part in the groups and benefited from the same. Her view regarding
the patient changed altogether after participating in the group.
Family Crisis Tberapy
During crisis situations, families have to be counselled very effectively so that
there is minimum impact of the situation on the patient's condition. The following case
illustrates a similar situation.
Case 33
Radha was an emotionally vulnerable person. Right from her childhood
she has had many affairs with men. They have all ended in failures. These
episodes have had a very severe impact on her. In spite of this she fell in love
again and this time he was another schizophrenic patient. This alerted the staff
and she was given counselling which did not change her attitude. Since this could
have a strong negative impact on her recovery and her treatment programme the
staff decided to meet her family members and let them know. A family crisis
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therapy was conducted for both the amicted families and sending one of them to
another half-way home reduced intensity of the problem.
This problem posed as a big challenge to the RMS staff as this involved the future
of two patients at stake. This was a crisis and the parents of both patients were called to
resolve this problem. Both the-families expressed-shock over the fact that their ward
were involved in a love affair. These kinds of affairs tend to bring about emotional
upsurge, which disturb the patients. These patients who are in the recovering stage run
the risk of relapse if they face any disappointment in their affairs. Therefore, it is in the
best interest of the patients and the families that these kinds of situations are checked.
Therefore, the parents had to be briefed with the problems that come along with this kind
of a situation.
Both the families could not accept the fact that consequences may occur if the two
patients marry. They felt that the problem of both their wards would be solved if they get
married to each other. The staff had to educate them on the grounds of the severity of the
situation if they allowed them to marry. To convince the two families the staff struggled
a lot. Each family had to be counselled separately and then together to understand the
situation. The patients were also counselled. Each stage was a very difficult process.
The families had to be counselled in such a way that one of them agreed to place
their ward in another organization. The staff felt that physical separation was the
immediate step to be taken to solving this problem. The family members were not happy
with the decision. Only when they were educated on the consequences that might occur
because of them being together at one place, did they realise the magnitude of the
problem.
One of the families agreed to place their ward in another organization. The RMS
staff arranged for the same. The families were also briefed about the effects that this can
hold on their wards. The families were worried and very anxious. The staff repeatedly
have sessions for the families to cope up with the situation. Ultimately, they succeeded
233

in dealing with the case. The families were happy at the end that the problem got solved
without any complications. These kinds of cnsis intervention need to be handled very
carefully and the RMS staff were relieved after the problem got solved.
Thus, the family is considered to be very resourceful in giving care and treatment
to the individuals and the voluntary organizations make maximum utilisation of the same
in order to bring about positive change in the patient's condition and also help the family
to maintain better mental health.
Indian family, in spite of the influences of westernisation, modernisation and
urbanisation, still possesses some positive traits that can pose as solution to problems in
health care in general and the care for mentally ill, in particular. Long-term care of the
mentally ill in halfway homes could be an exception but not the rule. The individual who
comes to halfway home for care and treatment is but pausing on a long and tiresome
journey homeward.... After having chen shed and loved should these individuals return to
society, only to be ravaged, savaged and rendered insane again?
The problem of care of the mentally ill poses a serious challenge to the society if
families go in the direction of abandoning these unfortunate victims of mental illness.
These halfway homes will llldeed become halfway homeless if society does not maintain
its social fabric. It is III the best needs of the society that regulatory mechanisms in the
society should be thought of before much harm is done. In this direction, the voluntary
organizations have been doing a commendable service to protect the charm of the Indian
family and encourage them to take care ofthe ill members.
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CHAPTER SEVEN
Summary and Conclusions
Being a mental patient has important consequences for the course of life and
social roles of the patient and the family. Care for the mentally ill is crucial, it involves
social and economic resources. Allover the world different strategies have been adopted
to tackle the problem of care for the mentally ill. Attitudes of the people have bee!}
changing since the days when mentally ill were tortured. Care for the mentally ill is very
important but yet due to financial constramts especially in a developing country like
India, facilities tum out to be meagre and alternative institutions of care have to be
evolved to tackle the problem. In order to fill in the dearth of services, voluntary
organizations have sprung up to provide complementary services. In the field of mental
health care, about 38 organizations are operating all over the country providing mental
health care services. In this study, an attempt has been made to assess the facilities
available in India and highlight the role played by voluntary organizations.
The major objectives of the study were the following:
1. To place the problem of mental health in India in a historical perspective.
2. To describe the role played by the voluntary organizations in the identification,
treatment, rehabilitation and prevention of the mentally ill.
3. To study the structure and functions of the voluntary organizations as related to the
care and cure of mentally disturbed patIents.
4. To examine the linkage of voluntary organization with the governmental organization
and with each other.
5. To understand the role played by the families towards the care of the mentally ill.
The study has been dealt in six chapters. Chapter 1 gives a brief introduction to
the problem, the theoretical framework used in the study and a survey of literature on
various aspects of mental health, viz., studies on public conception of mental illness, on
economic resources and mental illness and on families of the mentally ill, on the profile
235

of the mentally ill, on the institution of mental health care and on social factors and
mental illness. It has been found that in spite of the fact that there were a number of
studies on various aspects of mental health, much more is needed to be done on the
aspect of avenues open for the care of the mentally ill, the problems faced by the families
of the mentally ill in the process of rehabilitation of their family members, and 1he new
trends in the field of mental health care.
Chapter 2, places the problem of mental illness in a historical perspective, tracing
back to the treatment of the mentally ill during the 17 th century to the present
developments in the care of the mentally ill, evolution of the Indian concept of mental
health, brief description of mental health services in India and Sociology of Mental
Disorder. Until the 17 th century, the mentally ill were treated like criminals and they
were isolated from the community. Lunancy was attributed to Gods, the devil and the
moon. In the 18 th century, they were treated as beasts caged. Later, insanity became a
medical domain and the disease model was the preferred system for explaining the
lunatic behaviour. In the 19 th century, they were treated in asylums in a more humane
condition. Freud's psychoanalysis marked a great tum in the field of mental health as he
presented behaVIOur and mental functions as understandable. From then on theories
picked up on life stress, social support, network, etc.
Chapter 3 deals with the voluntary sector in mental health. In this chapter, the
importance of the role of voluntary organizations in the area of mental health is brought
in giving a brief picture of the facilities available in our country and the magnitude of
mental illness. The aspect of voluntarism is traced historically and the various aspects of
voluntarism, emergence, expansion, close-outs, strengths, weaknesses and their
relationship with the Governmental agencies are dealt with.
Chapter 4, deals with the three cases, the three voluntary organizations selected as
case studies. This chapter deals in detail the origin, location, objectives, structure,
leadership, staff, services, philosophy, approach, linkages and resources of these three
236

organizations. They are compar~d on all the above aspects and the positive traits of each
organization have been highlighted.
Chapter 5 deals with the Patient care provided by the three organizations. The
chapter deals in detail, the patients of the organization, identification of the problem of
the patients, services and therapies, vocational training and rehabilitation The
programmes for the patients are described and the various therapies that are offered by
the three organizations are described with the help of case studies. The kind of patient
care provided by the organizations depends on the philosophies and objectives of the
three organizations. The three organizations follow a unique pattern of their own.
Chapter 6 deals with the involvement of the families of the patients by the
organizations. The chapter deals briefly on the role of family as care giver, the changing
family system and the problems faced by the families of the mentally ill. With the help
of case studies the chapter illustrates how the voluntary organizations involve the families
in the process of care and treatment of the ill members.
The organizations that were chosen for the case studies were:
1) Mental Research Foundation (MRF), Madras
2) Manasa Rehabilitation Centre (MRC), Bangalore
3) Royal Medical Society (RMS), Bangalore
A Brief Summary of the Findings
Philosophy and Approach
All the three organizations aim at the rehabilitation of the mentally ill. Their
approaches differ because of the different phIlosophies followed by them. The three
organizations work on different philosophies with different approaches. MRF works on
the principle of behaviour modification. This approach attempts to change the behaviour
component of psychiatric disorders. In order to do this, the patient is encouraged to carry
237

out a behaviour that he dislik'!s but which the society approves. This is combined with
that of cognitive training that involves a change in their disordered ways of thinking.
Cognitive training and behaviour therapy go hand in hand. The therapists follow what is
called habit formation chart listing down the activities for each patient that enables them
to modifyLheir behaviour.
MRC works on the approach of transactional analysis. In this approach the
patients are encouraged to relate to one another in a b'fOUP. The half-way home is an
artificial community where one helps the individual to remain a social being by taking
more responsibility for himself and helping others share his feelings keeping in
communication all the time. The community acts as a therapist in helping him find his
own place back in the community. Contingency management is followed to bring
changes in the patients' undesired behaviour. It is based on the principle that if behaviour
persists, it is being reinforced by certain of its consequences and if these consequences
can be altered the behaviour should change. Similarly, a desired behaviour is brought
about by way of approval and praise. These reinforcements are brought about by
introducing token economy, (Incentives in cash) for desirable behaviours.
RMS works on the phi losophy of therapeutic community model. A great stress is
laid on understanding the human personality in health and illness from the context of
cultural and social factors in addition to individual variables. The trans-cultural
differences in phenomenology, course, outcome and treatment of mentally ill are
synthesised with the dynamic interaction with cultural factors. Inter-dependence is used
therapeutically to a large extent. The cultural forms of dependency and dependability
are made use of in an ongoing growth towards autonomy.
MRF's objectives are towards day care and long-term rehabilitation. It has a team
of psychiatrists working throughout which is lacking in the other two organizations.
Their day-to-day activities is more on vocational training and occupational therapy. The
patients are engaged in various activities and the products made by them are sold outside.
This is one of the sources of funds to the organization.
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In the other two organizations, viz., MRC and RMS, the patients are engaged
more on day-to-day routine activities, social skills training and various therapies that aim
at rehabilitating the patients in a short span of say, 9 to 12 months. The patients are
engaged in various activities that equip them to get back to their families to lead a normal
life. In both MRC andRMS, there is more stress on social skills training, which are more
useful in their every day life.
MRC depends more on volunteers to run the programmes for the patients. The
regular staff who are present in the organization number only three and every afternoon is
filled with sessions conducted by volunteers. These volunteers are not professionals in
the field of mental health care but experts in their own field, viz., drawing, pottery
making, yoga, games, etc. The psychologist and the social workers handle the therapy
sessIOns.
RMS has a very well equipped team of psychologist and social workers. This
group is trained in the philosophy of therapeutic community. They show real expertise in
handling the patients. Volunteers are also involved in the activities. Mostly they are
given responsibilities related to handling accounts and medicines. The experts handle the
therapies. Every day the statT involve the patients in innovative programmes that
brighten up the patients. Each day is different and one feels no monotony in their work
schedules. Whereas in the other two organizations, MRF and MRC, a routine and
monotonous activity takes place every day.
Staff of the Organ;wt;ons
The proportion of the staff to patients is a very important factor in delivering
proper care and treatment to the patients. This proportion is very small in the two
organizations namely, MRF and MRC. MRF has the great advantage of having five
psychiatrists throughout among its staff. Trained occupational therapists manage the
patients throughout the day. The psychiatrists, psychologists and the social workers
239

attend out-patients, register cases, follow-up cases and plan rehabilitation for the patients.
There are no innovative therapies for the patients. Morning till evening they are busy
with the occupational therapy. Interaction of the patients and the professional is very
minimal. In MRC, the situation is somewhat better, as each day is filled with different
kinds of activities. Though the interaction of the patients and the staff is better, their
proportion is very less and the staff cut-off themselves from the patients once the
volunteers take charge of the afternoon sessions. Participation of the staff during the
afternoon sessions is very minimaL Their role is more supervisory than participatory.
The proportion is very well maintained in RMS. There is involvement of the staff
in all activities. The staff members share the responsibilities and there is lot of variety in
the programmes given to the patients. The therapies are handled by experts. This makes
the sessions very interesting and lively. The mental patients require lot of motivation to
be lively participants and the staff members are very successful in bringing out the
congenial atmosphere of the patients. There is lot of seriousness and sincerity involved
in every programme they undertake. The stalT members meet frequently to assess their
performances.
Structure of the Organiuuions
The structure of the organizations determines to a great extent the facilities
available for the patients. The centres of MRF are highly crammed up. The rooms are
very small and the number of patients is more. The residential centres are located in the
suburbs in a large compound. However, the rooms allotted for the patients are very small
and congested. They resemble hospital wards.
MRC is housed in one of those colonial bungalows. There is a large open space
and a well maintained garden. There are separate buildings for the staff, residents, hostel
and an indoor auditonum. It has also provided living quarters for some staff members.
The patients feel very relaxed and comfortable with the stay. Privacy for the patients is
ensured. The rooms of the residents are also very comfortable and spacious.
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All the centres ofRMS are located in spacious buildings and are away from each
other. In each centre care has been taken to provide privacy for both staff and the
patients. The residential homes are very homely with lot of space and garden. The day
care centre is located in a calm residential area and has lot of space and a well maintained
garden. The occupational therapy rooms are very spacious unlike MRF. The staff are
provided with individual rooms that provides lot of privacy for the patients and the staff
during counselling sessions. RMS has been very successful in providing satisfactory
accommodation for the patients. The patients feel most cared for in this organization.
They are more relaxed and happy. Though MRC has maintained good facilities for the
patients, it has not been very successful with the patients probably because of the pattern
of therapies and activities followed in the organization.
Patient Care and Family Care
The therapies and approaches followed by the organization are the important
criteria in bringing about positive change in the patients. The three organizations differ a
great deal in this aspect. MRF follows a routine schedule. The psychologists work out
on various exercises in the lines of behaviour modification. The methods followed are
structured and formal. The social workers do not have a major role to play except for
making family visits and taking case histories. The relationships between the patients
and the professionals are very formal. The exercises are those of serious psychological
tests. Families are involved in some sessions. Crisis management and coping skills are
taught to the families. The organization has formed a self-help group of the patients in
order for them to solve the problems. The model followed is more towards a hospital
kind of treatment with more sessions with psychologists and the psychiatrists. The
patients are forced to engage in useful activity throughout the day in one of the vocational
activities. Group sessions are very rare and interaction between the professional staff and
the patients are very minimal. Patient care is on long-term basis both at the day care
centre and at the residential centres.
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MRC offers a more informal atmosphere than MRF. The patients feel very free to
communicate. The organization's stress is more on communication of the patients in a
group. Most of the programmes conducted aim at achieving self-expression of the
patients. In all their exercises, patients are encouraged to participate more in the group.
The stay of the patients is for a short term of one year. The objective of the organization
is to modify their behaviour in order for them to get back to the families. The interaction
between the staff and the patients is somewhat better compared to MRF. The patients are
involved in a learning process. Family sessions are conducted once a month. All the
families meet and air out their problems with one another. This exercise helps the
families to improve their coping skills. Since the organization's objectives are short-term
care, it aims at successful rehabilitation of the patients back into their families. As such,
there is regular review of the progress of the patients. Job placement is not attempted at
by the organization and as such vocational training and occupational therapy do not find
much importance in the activities of the organization. Patient care is limited to a short
period.
RMS otTers the most informal atmosphere for the patients that attract more
families and patients from all over the country. Their approach to patient care is highly
practical and natural. They emphasise on community living where the roles of the
patients and the staff are one of sharing of responsibilities of running the community.
Patient care is focused on training the patients on every day activities, which is expected
to equip them in managing themselves independently once they get back home. The
organization stresses on autonomy of the individuals, which is very essential for the
patients. The families are made to participate in every programme, be it an ordinary
household activity or a therapeutic session. The whole community of staff, patients and
families participate in the activities. In this manner, the organization staff make the
families understand the objectives of various therapies. The families are a very satisfied
lot as far as the organization's attempts are concerned. Admissions to patients are
restricted, as the staff are careful about the number of patients to be treated. Since the
programmes are focused on intensive training to the patients, they prefer a small number.
This reflects on the quality of care provided by the organization. Patient care is limited to
242

nine months in the half-way home. During these nine months, the patients are trained
with the objective of returning back to the families. They are sent back home once in
three months to see the changes and improvements. The families are involved at all the
stages and a feedback is got from them frequently to assess their changes. The last three
months of the stay of the patients is more focussed on independent management of the
self. Every three months in the organization is like graduation for the patients. The staff
orient the patients and the families on the philosophy of therapeutic community. The
combined efforts of the staff, patients and families have ended in many success stories of
the patients.
The three organizations have successfully utilised the resources of the family in
the process of care and treatment to the mentally ill individuals. At MRF, community
care programme has been introduced in the rural areas. Voluntary organizations have
tapped on the societal resources of family and community in caring for the mentally ill.
VOs have thus proved to be an extension service of the Government agencies. They
begin their services where the governmental organizations end. The aim of these
organizations in utilising the societal resources is not the end of cure but rather an
ongoing and long-term management of the society towards the care of the mentally ill.
These programmes provide the mentally ill with support systems to cope with daily life,
which is cost effective to the traditional model of institutionalisation and after care. They
facilitate the affected person to live in freedom in the community. Thus, therapeutic
intervention of the voluntary organizations in the family milieu accompanied by
community support goes a long way in preventing social deterioration that is so often
concomitant of the chronically mentally ill.
Problems and suggestions
Voluntary organizations need to be very focussed in their objectives and not be
too ambitious for it may dilute their objectives. More funding should not lead to
widening of objectives, rather it should be used to focus the objectives sharply.
Expansion should be made with caution in order to maintain quality of the services.
Conflict of interests among staff is inevitable in any organization. Most of the time, this
243

leads to mistakes, which warrants correction. Rehabilitating schizophrenic patients is a
very complex task. To start with, rehabilitation should be attempted for a few patients
Attempting with a large number is a very cumbersome task and leads to complex
problems.
VOs have a very unique problem of staff turnover. They cannot hold on to their
staff for very long. Male staff discontinue their jobs to switch over to better remunerative
jobs. Only those for whom earning from VOs is a secondary means of livelihood,
continue to hold on to their jobs, as it is mostly secondary means of livelihood. More
volunteers should be trained and involved in the programmes for the mentally ill under
the supervision of the professionals. Those who are willing to work committedly and
sincerely and for whom income is not a necessity should be encouraged and trained by
the VOs to overcome the problem of staff turnover. But professionals have to be paid
well so that they stay on with the organization. May be employing a few professionals on
high salaries and more of volunteers could help the organization to achieve a good
balance of professional expertise and community involvement.
VOs have a good team of professionals, dedicated and efficient in handling
matters. This team could be more involved in educating the masses on mental illness
with a focus on removing the stigma attached to the illness. Networking of all the
voluntary organizations and forming more self-help groups consisting of family members
and other community members would go a long way in helping the society deal with this
problem. Job centres could be started wherein the patients could be rehabilitated. This
would help the patients in being self-reliant and also ensure them of a professional care in
their future. The training programmes could include some programmes for the general
mass and interested persons could be trained as volunteers on symptoms of mental illness
and also coping skills. This would help in providing a social support system for the
mentally ill. This programme could also be extended to the rural areas where there has
been a lag in psychiatric services.
244

Contribution ofTbis Study to Mental Healtb Care
This study highlights the importance of a multi-disciplinary approach in the field
of mental health care. Care, treatment and rehabilitation of the mentally ill rests not in
the hands of the psychiatrists alone but depends on different professionals, the family
members and the community. Every individual in the society has a role to play in
making life better for the mentally ill.
Voluntary organizations have successfully tapped the various societal resources to
cater to the needs of the mentally ill. Cure of the mentally ill depends not just on
medicines but something beyond that. The active involvement of the social workers,
sociologists, anthropologists in the field in trying to probe into the attitudes of the
community towards the mentally ill and improving the coping skills of the families go a
long way to help the mentally ill. The inclusion of experts in the fields of arts and crafts
not only helps III engaging the patients in useful activities but also imbibes responsibility
in the experts to share the burden of the society to take care of the mentally ill. The
inclusion of the volunteers in the programmes is a positive sign towards more
participation of the community members in the care of the mentally ill. Family based
care and community based rehabilitation is the ultimate solution to the mentally ill which
is cost-effective and on a long term basis.
Limitations
The study is confined only to the three voluntary organizations. The study could
have included more voluntary organizations, but due to time and other constraint only
three organizations have been studied. The subject of traditional methods of healing have
not been covered in the study, though reference has been made m the chapters. This is a
vast subject and can itself become an independent study. Similarly the
professionalisation of the mental health care staff has not been covered in detail as it does
not fall under the objectives of the study. However, it is another interesting subject that
requires special attention.
245

Major findings
1. In all the three cases one can see a slow shift from pure medical model of care to a
social model of care. A good mixture of both determines the success of the
organization.
2. There is a significant paradigm shift from pure medical based techniques to
community based and family based techniques.
3: Among the three organizations MRF and RMS have successfully managed to sustain
their activities and also expand with their own resources and partly by external
funding. Whereas, MRC has not been able to expand much on its activities mainly
due to its inability to mange its own resources.
4. The organizations are predominated by female staff and female volunteers.
5. The staff structure and the infrastructure facilities in the organizations determine to a
great extent the quality of care delivered to the mentally ill.
6. The benefiCiaries of the organization are of different economic classes and hail from
both urban and rural areas.
7. The three voluntary organizations playa great role in complementing the services of
the Government. Though their number of beneficiaries is small, their services are
highly significant.
8. The models followed by the three organizations differ. Each one has been successful
in achieving their objectives.
9. MRF with its highly professional staff has been highly successful in long term
rehabilitation of the patients and has also in a wide coverage of activities and
beneficiaries.
10. MRC has been successful in achieving short-term care for the patients and successful
rehabilitation of the patients back into their families.
II. RMS is the most successful of the three in all aspects of patient care. Due to its
success in rehabilitation, it has now expanded its various activities by starting day
care centre, group homes for rehabilitated patients who manage themselves alone in
the lines of long term rehabilitation and a post graduate course on psychiatric
rehabilitation.
246

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