Indian Joumal of Psychological Medicine, 2001, 24(1) Pp 46-52

RESEARCH PAPER I

DAY CARE OF THE CHRONIC MENTALLY Ill: PUBLIC RESPONSE IN KERALA TO MEDIA ANNOUNCEMENT

Dr. L.S.S. Manickam, M.A., muasp., PII.D.*

ABSTRACT Realising the need for rehabilitation services in Kerala, it was planned to open a day care centre in the capital ciiy, Thiruvanathapuram, in the southern district of Kerala. The announcement was made through a print media and the responses to avail the services of the centre are reported. Only one person contacted personally for help and there were 38 people who responded through mail. Majority of the respondents was from other districts of Kerala and there were requests from outside Kerala. Though it was expected that the relatives of the chronically ill would respond, there were enquires from patients, friends and neighbour of mentally ill. Request for sedces came from more number of men than women and it might be a reflection of the socio cultural role expectation of the male gender of this society The study points towards initiating psycho educational programmes on rehabilitation for the relatives of the chronically mentally ill to help the patients and to ease the burden of the families. Key Words: day care, chronic mentally illness, media day INTRODUCTION Care and rehabilitation of the chronic mentally ill people pose a great challenge to the mental heatth professionals of our country. Viewed from a National perspective the task is very much complicated due to socioeconomic, linguistic, demographic and cultural diversity. Though rehabilitation psychiatry in our country is in its infancy (Kuruvilla, 1994) several rehabilitation programmes and services have been initiated at different states of our country

(Gopinath & Rao, 1994., Thara & Joseph,1995). Varghese (1994) identified the problem areas encountered in rehabilitating the mentally disabled in our country as those related to the patient, the psychiatric hospital, the family dynamics and the attitude of the community. He opined that the negative attitude of the community to mental illness itsetf is a hindering factor of psychiatric rehabilitation of mentally ill. Day Care Centre is considered as one of ways of rehabilitation which provide, a supportive, long term management and maintenance oriented service for the chronic patient. Rao, et. al., (1988) assessing the burden in families of patient with chronic schizophrenia, suggested the need for more day Care Centres, which can provide the much needed respite for the burden of the families. Nagaswami, et. at., (1985) emphasised the importance of vocational training in day Care Centre, which enable the patients to retrain in skills which may lead to gain employment. The need for opening more number of day Care Centres in our country with the participation of the community through voluntary agenciesin order to provide psychosocial rehabilitation has been raised in different forums (Kuruvilla, 1994., Gopinath & Rao, 1994., Reddy, et. al., 1988). Kerala State though has very good social and health indices when compared to other states in India, so far has not kept the pace of growth in the area of providing rehabilitation services to the mentally ill. In the, 1980's Krishnamoorthy, (1 983) was appointed by the State Government to conduct an enquiry into the working of the mental hospitals

*Director, Centre for Applied Psychological Studies, Baith Shalom, Thirupuram, Thiruvananthapuram 695 133.

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in Kerala. After a thorough investigation he recommended a comprehensive programme for psychiatric rehabilitation in Kerala. The programme envisaged Rehabilitation Clinic, half-way homes, Day Care Services, Self employment, Job placement, and a special Mental Health and Rehabilitation fund, for rnobilising money for meeting the rehabilitation services. Realising the importance of psychiatric rehabilitation and unavailability of day care centre within the city, a group of mental health professionals, under the patronage of Manasasthram, a monthly publication devoted to psycho - medical - family issues planned to open a day Care Centre in Thiruvanarrthapuram the capital city of Kerala. In this study, the public response to the announcement that was given in the magazine regarding the services of day Care Centre for the chronic mental illness are analysed. MATERIAL AND METHODS Stage I Manasasthram (Psychology) is a monthly, psycho- medical-family magazine, in Malayalam, which started publication in 1977 from Thiruvananthapuram. The magazine published from Thiruvananthapuram is widely distributed over the entire state of Kerala through newspaper agents. It also has regular annual subscribers and life subscribers and is sold at public newspaper and magazine selling stalls in the entire state of Kerala. Moreover, it also has circulation through out India and abroad among Malayalam speaking population. As part of Manasasthram, a psychological service providing Centre, Insight has been functioning since 1982. Insight decided to start a day care Centre for the Chronic Schizophrenic patients at Thimanathapurarn, within thg city limits. In order to assess the demand of the day care Centre among the public the following announcement was published in Malayalam in single page in the magazine.

"There are a number of people who are chronically mentally ill, and are home bound. Apart from the treatment through pharmacological means, rehabilitating them is also equally important. They need to learn to reschedule their activities during daytime. Therefore the importance of day care centres assumes prominence. Psychosocial and vocational training plays an important role. Insight, on behalf of Manasastrum is opening a day care centre for the chronic mentally ill persons with in Thiruvananthapuram City. The major objectives of the day care centre are to provide psychosocial management and occupational training to the chronically mentally ill and to provide psychosocial support to the family members. The services would be rendered under the supervision of mental health experts. The relatives of the chronically mentally ill who require the services of the Centre are requested to contact the Centre directly or through mail. Kindly furnish the following details - Age, gender, educational qualifications, place of domicile, religion, income, if employed in the past jobs held in the past and nature of work done, nature of illness and details of present treatment."

The same message was repeated in three consecutive issues of the magazine. Prior to the announcement there were articles written about the importance of rehabilitation to the chronic mentally ill. Stage II SAMPLE All the letters received during these three months period and the following three months formed part of the study. There was only one personal inquiry regarding the services. However 39 letters which were received. Of these, one was a reminder to an earlier letter of enquiry. The available information obtained from the remaining 38 letters were

Indian Journal of Psychological Medicine, 2001. 23( 7) --.

analysed. relatives, friends, or neighbours. Among the RESULTS relatives, the male relatives especially siblings have

shown more concern, than female relatives. And it Place of enquiry: Only one person had approached is interesting to observe that a neighbour had also the centre in person to get information about the taken initiative to enquire about the services. day care centre. Of the 38 letters received, only 30 had mentioned about their place of residence. There TABLE were enquiries from all the 13 except one-revenue districts of Kerala. Though the majority of the 38 responses were from within Kerala, there were enquiries from outside Kerala, with one each from Bangalore and Bihar (table 1). The highest number of enquiries had come from Kottayam, central Kerala. Though the day Care Centre was planned to be functional at Thiruvananthapurarn, there were only 4 enquiries from the same revenue district.

TABLE 1 Respondents plain of domlcile

Respondents

Place of enquiry Tiunrvananthapuram Kollam Pathanamthitta Kottayam ldukki Alleppey Emakulam Thrissur Palakkad Malappuram Kozhikkodu Vayanad Kannur Bangalore Bihar Total

Data related to Patlents

n=30 4 1 1 6 2 1 1 2 1 2 4 1 2 1 1 30

None of the enquiries contained all the required information. The available socio-demographic data of the patients are provided in Table 3. There were 33 (76%) men and 5 (24%) women who enquired about the services. Only 21 had given their age and majority of the patients was in the age of group 20-40. The number of patients in the age interval of 21-30 was more-when compared to other age groups and the mean age was found to be 29.62. The educational status of only 16 subjects were available and majority of them (50%) had educat~on up to X standard only. However there were 2 postgraduates. Economic level of the 12 patients showed that, 9 of them were from low socio economic income group and 3 were from high

While 32 respondents provided their identity, 6 did socio economic level. Seventy-five percent of the not reveal their identity (table 2). 18 letters (56.25%) sample belonged to poor or very poor economic were written by people who identified themselves status. Six of the respondents reported that they and the rest of the 13 letters were from either had held jobs in the past in different work settings

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TABLE 3 Soclo demographic detalls based

on lnformatlon provlded I Variables I N o I % I

Gender (n 38) Men Women

Age (n 21) 10-20 21 -30 31 -40 41 -50

Education (n 16) X Std and below XI1 Degree Post Graduate

Occupation (n 6) Manual Labour Skilled (Dubai) Bank Business Receptionist

Income (n 1 2) Very low Low High

and majority held skilled jobs. None of the letters provided information on illness, duration of illness, or the treatment details. The letters stated, "Being ill for some time ...", "Ill for the past few years...", "Being ill for long time ... " etc. DISCUSSION The fact that the patients themselves have taken more initiative in seeking out the rehabilitation services than relatives may lead to several interpretations. Since the details of illnesses were

not mentioned, it is difficult to conclude whether the respondents were chronically mentally ill or not. It is possible that, persons who had perceived themselves as having undergone a psychiatric illness have considered day-care as a means to cope with their day to day problems. Another possibility is that the Patients, though chronically ill and who have perceived lack of social support from the families could have considered vocational rehabilitation, inorder to gain some form of employment. Or the relatives with high social support would have encouraged the patients to enquire about the services of the day care centre. Majority of the respondents were well educated, which may be a reflection of the high literacy of the State. And the occupation held by the patients also show the same trend, that the skilled employees seeking services of the centre to get back to some form of employment. Since majority did not provide information about the jobs held, a generalisation in this regard has to be made with caution. The respondent's economic status level requires further explorations. Though the low income and high income groups have acknowledged their Income level, the middle income group has either not responded or hesitated in reporting the income level. However, taking into consideration of the financial burden caused by mental illness on the family (Kuruvilla, 1995), the low-income level may be finding it difficult to cope with burden and hence explores the alternatives. The high-income level on the other hand, is aware of the financial burden and may be looking for a solution to contain the financial drain. Probably, the middle class, over a period of time has learned to adjust with the cost of mental health care within the available financial resources. As observed earlier (Manickam and Zhandran, 2001) an extensive exploration, into the psychological, social, economical and cultural issues related to chronic mentally ill patients in Kerala, is an urgent need to develop strategies for caring the mentally ill.

Indian Journal of Psychological Medicine, 2001, 24(1)

The finding that more number of males had 1998b). responded than females may lead one to ascertain the gender differences observed in caring the chronically mentally ill (lhara & Joseph, 1995., Manickam & Chandran,1998, 2001). One of the reasons could be the increased burden that the male member may pose to the family (Mors, et al., (1 992). Thara & Joseph (1 995) found males to be more disabled in occupational functioning as well as in global disability. Male patients seem to be more disabled at the end of 10 years. In their study, they found women to be functioning as full time housewives, and on the other hand there was pressure on men to act as the primary / secondary breadwinners. Under employment or erratic employment coupled with under achievement could well act as threats to the social status of men in our society and hence there is a need to provide rehabilitation services to them to gain some form of employment. Moreover, in Kerala population, the relatives were found to express a higher rejection response to male patients than the female patients (Manickam and Chandran, 1998). The fact that the request has come from more number of patients than their relatives, friends and others may also reflect the general attitude of the readers or the public towards rehabilitation of the chronically mentally ill. The monthly magazine Manasastram has been featuring articles on rehabilitation, and therefore it is unlikely that the readers lack information and knowledge about rehabilitation. Since there is a high rejection feeling of relatives of chronic mentally ill people in Kerala (Manickam & Chandran 1998) and this study has found less number of people being prepared to avail the rehabilitation services, innovative programmes have to be initiated to change the attitudes of the family members and relatives. The negligible response is also a pointer to the service providers to chart out and initiate psychosocial education programmes, for the relatives of schizophrenic patients similar to the ones conducted by Prema & Kondandaram (1 998a,

Gopinath et at., 1987 observed that at NIMHANS, Bangalore, where there are very good facilities for rehabilitation and separate department of Rehabilitation psychiatry, twenty - five percent of the patients referred to the day care centre tends to discontinue the services offered. They found that the rejection of services was related to education, marital status, family's attitude to day Care Centre, and past occupation held by the patient. Kerala is highly literate and health conscious and has high health and social indices, Probably, the public is largely 'informed' about various aspects of mental health including the rehabilitation. However these are not reflected when it comes to rehabilitation services. As far as the human resources are concerned 157 (8.67%) of the psychiatrists (IPS, 2000), and 26 (8.67%) of the clinical psychologists registered with IACP (IACR 1998) in the country are currently working in Kerala. In practical terms, there is more number of mental health professionals working in Kerala than the above figures who have not yet registered with any of the professional organisations. But the number of rehabilitation Centres meant for the Chronically ill are only three. From the Parents and relative's perspective the neglect towards availing the rehabilitation services could be due to various reasons. However three issues stand out, 1) The social stigma, Mental illness is considered as a curse, caused by devils and other evil forces and therefore, it is psychologically distressing to acknowledge the mental illness of a close relative (Ramachandran & Manickam, 1997). Due to anticipated fear of social isolation, the families, who are aware of the day care centres, do not send them out of their house or residential care centres and facilitate the patients to socialise with other people, especially with those in the locality where the family lives. 2) Inadequate education on Rehabilitation. Some of the families who are willing

Dav Care of the Chronic Mentallv 111

to provide social support to the patients do not have adequate knowledge and information about psychosocial management. Most often they hold the view that apart from pharmacological management the psychiatry profession has nothing more to offer to the chronically mentally ill person and hence search out for other unscientific and 'alternate' methods, which most often turns out to produce negative results. 3) Differences in priories of families and the mental health professionals. In terms of caring the mentally ill, the priorities of relatives could be different from those seen from the perspective of illness (Bacharnch, 1992). As Kuruvilla (1 995) has opined, probably the parents of the chronically ill patients are more preoccupied with the question of "who will look after the patients after their life time ...." (P 103) and are interested in their life long care, rather than providing them with psychosocial rehabilitation. Rehabilitation has never been a serious agenda of the services of the mental hospitals in Kerala. The commission of enquiry on the working of Mental Hospitals in Kerala, in its report strongly recommended the need for rehabilitation services to be offered at the District and Taluk Centres (Krishnamoorthy, 1983). But till now it has not been implemented. Krishnamoorthy (1 983) wrote, "The comprehensive Rehabilitation programme can help to rehabilitate only a small portion of the mentally handicapped, even if it is implemented with full vigour and on extensive scale. Large number of mental patients who have recovered from the illness but unable to find any livelihood, social acceptance or help from their families would still remain, spread over the whole state who, if a timely helping had is not extended, might find their way back to the Mental Hospitals. In most cases their families are unable to support (p.47). Government hospitals in cities can initiate the rehabilitation programmes, if a multidisciplinary team is available. Since the number of professionals in Government sector are low, the services of the

senior post graduate students of psychology who specialise in clinical psychology and health psychology, social work students who specialise in psychiatric social work, Nursing students specialising in Psychiatric Nursing and Occupational therapy students can be utilised for both psychosocial education and rehabilitation (Manickam, 1992), Ponnuswami's (2000) suggestion to make use of the services of the University departments in providing community mental health care may also help ease the task of 'caring the unreached. However, the responsibility of taking lead in helping the chronically mentally ill to a great extent rests with the mental health professionals. It may require that psycho-educational programmes need to be conducted regularly and repeatedly for the relatives to change the attitudes, to be less socially restrictive and to learn skills in behavioral communication (Fadden G. 1995). The relatives need to be educated about the importance of learning the social skills by the patient, especially the skills in improving the interpersonal relationships (Prema 8 Kondandaram 1998b). Or as an alternative, family participation during the treatment of could be given an experimental trial (Varghese, 1988., Kuruvilla, 1994). REFERENCES: Bacharach, L.L. (1992). Psychosocial rehabilitation and psychiatry in the care of long-term patients. American Journal of psychiatry, 149, 1455-1 463. Fadden G. (1995). Behavioural family therapy approaches to the treatment of schizophrenia. In C. Mace & F. Margis (eds.). Psychotherapy of psychosis (pp. 181 -1 95) London: Gaskel. Gopinath, F! S., & Rao, K. (1994). Rehabilitation in psychiatry: An overview. Indian Journal of psychiatry, 36,2,49-60. Gopinath PS., PS.V.N. Sharma & Reddy, XV. (1987). Patients who discontinue day hospitalisation - An analysis. Indian Journal of psychiatry, 29. 197-20 1.

lndian Journal of Psychological Medicine, 2001, 24(1)

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