|Year : 2019 | Volume
| Issue : 4 | Page : 306-310
Women with mental illness – An overview of sociocultural factors influencing family rejection and subsequent institutionalization in India
Febna Moorkath1, Mysore Narasimha Vranda1, Channaveerachari Naveenkumar2
1 Department of Psychiatric Social Work, NIMHANS, Bengaluru, Karnataka, India
2 Department of Psychiatry, NIMHANS, Bengaluru, Karnataka, India
|Date of Submission||20-Mar-2019|
|Date of Acceptance||18-May-2019|
|Date of Web Publication||15-Jul-2019|
Department of Psychiatric Social Work, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Family abandonment and rejection resulting in homelessness are detrimental to women diagnosed with mental illness in India. A majority of the literature related to homelessness holds a western background, and women's homelessness in relation to mental illness is relatively unexplored in the Indian context. This review was conducted to understand the sociocultural factors influencing family rejection and to synthesize the living situation of institutionalized women with mental illness in India. Methods: Literature search in electronic databases (PubMed, Google Scholar), carried out using appropriate keywords, and a manual search in the library catalog. Results: As per the selection criteria, 19 reports, including original research articles and conceptual papers, were included and reviewed. Conclusion: There is a shortage of methodologically sound research in understanding the connection of mental illness–women homelessness–and the institutionalization scenario. This review highlights the necessity of shifting focus from institutionalization to innovative psychiatric rehabilitation strategies using the Mental Healthcare Act, 2017.
Keywords: Homelessness, institutionalization, psychiatric rehabilitation, women with mental illness
|How to cite this article:|
Moorkath F, Vranda MN, Naveenkumar C. Women with mental illness – An overview of sociocultural factors influencing family rejection and subsequent institutionalization in India. Indian J Psychol Med 2019;41:306-10
|How to cite this URL:|
Moorkath F, Vranda MN, Naveenkumar C. Women with mental illness – An overview of sociocultural factors influencing family rejection and subsequent institutionalization in India. Indian J Psychol Med [serial online] 2019 [cited 2019 Oct 16];41:306-10. Available from: http://www.ijpm.info/text.asp?2019/41/4/306/262682
Mental health is a crucial element in the overall concept of health, which equally strives toward the physical, emotional, social, and spiritual aspects. The extent of prejudices and sufferings faced by the people diagnosed with mental health disorders has been demonstrated in research. Considering the Indian social scenario from a patriarchal framework, women diagnosed with mental illness undergo a variety of gender-specific issues in individual, familial, and social facets. This specific population has to face an unsupportive world while managing their inner disturbances caused by the various psychiatric symptoms. The occurrence, manifestation, treatment, and outcome of mental disorders in women in India need to be understood in relation to the specific norms which act as guiding principles  in the society.
The stigma and discrimination in relation to mental health and their potential impact on marginalization are well documented in the literature, ranging from denial of opportunities to social and cultural exclusion. In India, multidimensional poverty and the stigma associated with severe mental illness is pervasive; and for women, it is reported to be a strong indicator of poverty. The prevalent interaction between stigma, mental illness, and gender meant women in those conditions was more prone to be poor than men.
The immediate family is primarily the care providers for people with mental illness in India. However, the label of mental illness in relation to the female gender often creates difficulty in familial and marital contexts. It is impossible to evaluate the scenario of women in isolation; rather, it needs a comprehensive understanding of the different interacting social structures and cultural norms. The current review has represented the nexus of mental illness–family rejection–women homelessness–institutionalization specific to the Indian scenario. This review was an attempt to answer two main questions considering the Indian social climate:
- What are the sociocultural factors influencing families to reject/abandon women members diagnosed with a mental illness?
- What is the living situation of women placed in the shelter of care homes/psychiatric hospitals due to various psychosocial circumstances?
| Methods|| |
Relevant studies and reports were identified through a combination of different electronic database and Internet searches, and cross-reference searches of retrieved documents. A systematic database search was conducted in PubMed and Google Scholar. A manual search in the library catalog and Google search to find out relevant reports that are not included in bibliographic retrievel systems was also carried out to find out any grey literature. The literature review process was carried out through literature searches, storing, making abstracts of retrieved documents, and synthesis.
Criteria for selection
Considering lacunae in published original articles in the intended area, other than peer-reviewed articles, relevant documents and reports of government or nongovernment organizations published in the English language available on the Internet were included in the review. Original articles included both quantitative and qualitative studies which focused on any of the components regarding women with mental illness–family rejection–homelessness–institutionalization.
Restricted vocabulary/search terms
The literature search was mainly focused on a two-tier strategy – an electronic search and a manual search. Keywords such as women with mental illness, marriage, stigma and discrimination, gender, patriarchy, homelessness, institutionalization, family rejection, shelter care homes, psychiatric hospitalization, psychiatric rehabilitation, along with women and India, Indian setting/context/society, and Indian culture were used to identify relevant literature.
| Results|| |
Women with mental illness – sociocultural and familial response
Families' perception toward women with mental illness plays a critical role in the treatment and caregiving process. Indian families are tolerant of deviant behavior and at most times are ready to take care of the ill member. However, cases of familial rejection and abandonment also seem to be rampant due to multiple reasons:
- Helpless abandonment: This happens in a majority of families. Poverty, lack of support, inability to meet the cost of medications, inability to travel long distances for care, elderly caregivers, stigma, suboptimal living conditions, unsafe neighborhoods, and so on
- Careless abandonment: It appears when the primary caregivers, especially parents, get old, and the other family members are not ready to shoulder the caregiving responsibility of the person with mental illness
- Willful abandonment: It is the intentional dumping of the mentally ill family member by other significant relatives due to vested interests such and getting divorce and property.
The marginalization of women is reported to be in three aspects: first is the female status, the second is the psychoses, and the third is the marital status (divorced/separated).
Prevalent stigma (stereotypes, prejudice, and discrimination)
The stigma toward mentally ill women often leads to their marginalization, which in turn creates barriers to their recovery. Prevalent stereotypes spread negativity toward the mentally ill; the prejudice results in cognitive or affective responses like anger or fear toward such people, and this finally leads to discrimination, rejection, and avoidance from the society., Reported evidence from southern India has indicated that young women with schizophrenia are more vulnerable to discrimination within society.
Indian families, marriage, and gender roles
The family is regarded as the nucleus of the Indian social system. Unlike the Western scenario, Indian culture follows a collectivistic attitude which places the family in the center of individual lives. Marriage for women in India, ideally considered being one time, is colored with social conformity and sanction. Hence, broken marriages due to mental illness shatter the lives of these women. The marriage and familial roles are strictly gender-based, wherein men involve in active familial affairs, whereas women possess a marginal and passive role. Factors such as joint family system, patriarchy, marriage as a necessity, subservient status of daughters-in-law at home, preference for a male child, dowry, lower educational status of women, strict gender rules, and the primary roles of women being childbearing and nurturing have a major influence in the lives of women in India. There is a strong inverse relationship between social position and health-related outcomes. Therefore, the social disadvantages experienced by Indian women prove that biological vulnerability effect is exponentially higher. In India, where 90% of marriages are arranged by the families, the fact of mental illness in the case of female members heavily burdens them. Other factors such as poverty, deprivation, illiteracy, stigma, lack of community resources, domestic violence, family rejection, abandonment, and death of primary caregivers evidently result in homelessness of women with mental illness.,
A comprehensive report published by World Health Organization  elaborately explains the link between increased prevalence of mental health issues in women and their vulnerability in a patriarchal society. Women with mental illness appear to be at a particular disadvantage in India. Thara et al. mentioned in their study that such women were frequently sent back to their family of origin and their responsibility borne by their old parents. The women and the family experience social isolation and stigma., They are abandoned mainly due to the negative attitude toward the illness rather than the illness itself. Broken marriages and separation in the context of mental illness meant that many caregivers felt depression and sorrow and experienced a large amount of stigma within the society.
Families abandon and reject their mentally ill members due to the taboo deeply rooted in shame. In an unsupportive family environment, access to mental healthcare and maintenance of treatment remains a question. Neglect eventually leads to abandonment; as such, homelessness is the most common outcome for these women. Irrespective of the severity of the symptoms, this segment is considered to be the most marginalized and deprived of all human and civil rights. A court-based study to analyze the judgments related to annulment and divorce in the background of mental illness revealed that in the Family Court at Pune, 85% of the cases were filed by husbands who alleged that their spouse was mentally ill. Among cases reaching the High Court, 95% were filed by male petitioners.
The failure in gender role establishment seems to be interfering with the lives of women, more so in those with mental illness. Viewing from a gender perspective, decision-making and access to property allow for minimal involvement from women. For example, in the case of married and unemployed women, decision-making ability is restricted to the kitchen. Whereas men, despite any illness, are involved in every decision-making process. The women were denied property rights by the family due to the presence of psychiatric illness. In the marital context, separation and divorce were reported more in female patients, predominantly those who were symptomatic or childless. Evidence suggests that women are being deserted by their spouses without any maintenance support.
Research underscores the fact that in most developing countries, the numbers of mentally ill women who become homeless seem to be increasing. This is due to the disorganization of the joint/extended family system and an increase in transportation facilities which cause such women to wander off to different places. Some families are even hostile and indifferent toward these women when sent back home. This may be due to moralistic reasons and the stigma associated with the mental illness. The women abandoned by their family are often sent to institutional facilities for long-term care and protection.
Institutionalization and living conditions of Indian women with mental illness
In 2014, a report published by the Human Rights Watch (HRW), named “Treated worse than animals-abuses against women and girls with psychosocial or intellectual disabilities in institutions in India,” created a good deal of discussion in both government and nongovernment platforms. HRW identified that stigma, discrimination, a lack of appropriate governmental community-based services, and a lack of awareness about facilities and available services for people with a disability often lead to institutionalization. The interviews with the respondents highlighted harsh realities like forced institutionalization, abuse in institutional care, including neglect, physical, and verbal abuse, and involuntary treatment.
Following this report of HRW, National Commission for Women and National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru (2016), conducted a study to address the concerns of women admitted to psychiatric institutions in India, to explore the clinical, social, cultural, and economic factors likely to affect the lives of women with mental illness admitted to mental health hospitals within the country. HRW's report selectively highlighted the abuse in Indian institutions. The study, however, reported reasonable satisfaction of women with mental illness regarding the facilities provided to them. On a closer examination, it has been concluded that many of these women came from difficult backgrounds deprived of basic facilities, and the availability of such facilities led to reasonable satisfaction among these women. In this report, women staying in some institutions expressed high level of dissatisfaction with basic amenities such as safe drinking water, facilities to sleep, rest, wash, and dry clothes.
A study conducted in West Bengal by the Ministry of Health and Family Welfare in 2013, to form a draft policy for psychiatric rehabilitation of long-stay patients in state-run mental hospitals, revealed that out of five state-run psychiatric hospitals, four are overcrowded with long-stay patients who are stable or fit to be discharged; many being abandoned and the families not ready to shoulder the responsibility. The study also highlighted the need for strategic interventions to improve the condition of long-stay patients who have no one to care for them.
The National Commission for Women (2006), in collaboration with Sane and Enthusiast Volunteers' Association of Calcutta (SEVAC), explored rehabilitation of female mentally ill in psychiatric hospitals in Kolkata. The study mentioned that the living conditions of people inside the psychiatric hospitals are very pathetic, even violating basic human rights. Physical torture and lack of humane care are the main flaws in these systems, and the report continued that some female patients were even kept naked due to several reasons. The study revealed that a majority of patients (60%) indicated poor quality of life and the study also identified that government infrastructures for the delivery of mental healthcare are inadequate for ensuring treatment compliance.
| Conclusion|| |
It is clear from the current review that the sociocultural involvement in the lives of women with mental illness is visible in India. The available literature underscores the prevalent gender-specific explanations and their influence in the aftercare activities. There is a lack of evidence-based studies to explain the nexus of mental illness–homelessness–institutionalization. There is an alarming need to shift the focus toward community-based psychiatric rehabilitation rather than sticking to the conventional mode of institutionalization. In Mental Healthcare Act 2017, Chapter v, section 19, the right to community living is highlighted as one of the basic rights of people with mental illness, and it directs the Government to make necessary arrangement for establishing or supporting less restrictive community-based establishments. The Act also mentions Government support in free legal aid measures for abandoned people with mental illness to exercise their right to live in the family/home. The right to community living should be highlighted in the major platforms of research and policy initiatives to address the needs and concerns of the institutionalized and invisible population.
Financial support and sponsorship
This review is part of a Ph.D. work which is funded by UGC/SRF (University Grants Commission-Senior Research Fellowship Award Letter Number-1336/2013).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Callahan D. The WHO definition of health. In: Smith M, Strauss S, editors. Pharmacy Ethics. 1973. p. 95-104.
Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al
. National Mental Health Survey of India, 2015-16: Prevalence, Patterns and Outcomes. Bengaluru: NIMHANS; 2016.
Chatterjee R, Hashim U. Rehabilitation of mentally ill women. Indian J Psychiatry 2015;57:S345-53.
] [Full text]
Murthy P, Naveen Kumar C, Chandra P, Bharath S, Math SB, Bhola P, et al
. Addressing Concerns of Women Admitted to Psychiatric Institutions in India – An In-depth Analysis. New Delhi: National Institute of Mental Health and Neuro Sciences and National Commission for Women; 2016.
Sharma I, Pandit B, Pathak A, Sharma R. Hinduism, marriage and mental illness. Indian J Psychiatry 2013;55(Suppl 2):S243.
Mahomed F, Stein MA. De-stigmatising psychosocial disability in South Africa. Afr Disability Rts YB 2017;5:64.
Trani JF, Bakhshi P, Kuhlberg J, Narayanan SS, Venkataraman H, Mishra NN, et al
. Mental illness, poverty and stigma in India: A case–control study. BMJ Open 20151;5:e006355.
Chadda RK. Caring for the family caregivers of persons with mental illness. Indian J Psychiatry 2014;56:221.
] [Full text]
Bhatti RS, Janakiramaiah N, Channabasavanna SM. Family psychiatric ward treatment in India. Family Process 1980;19:193-200.
Thara R, Kamath S, Kumar S. Women with schizophrenia and broken marriages – Doubly disadvantaged? Part I: Patient perspective. Int J Soc Psychiatry 2003;49:225-32.
Corrigan PW, Watson AC. Mental Illness and Dangerousness: Fact or Misperception, and Implications for Stigma.
Phelan JC, Link BG, Stueve A, Pescosolido BA. Public conceptions of mental illness in 1950 and 1996: What is mental illness and is it to be feared? J Health Soc Behav 2000;41:188-207.
Thara R, Srinivasan TN. How stigmatising is schizophrenia in India? Int J Soc Psychiatry 2000;46:135-41.
Malhotra S, Shah R. Women and mental health in India: An overview. Indian J Psychiatry 2015;57(Suppl 2):S205.
Gopikumar V. Understanding the Mental Ill Health–Poverty–Homelessness Nexus in India: Strategies that Promote Distress Alleviation and Social Inclusion; 2014. Available from: http://www.ihrn.org.in 17/04/17
. [Last accessed 2018 Feb 05].
Dennerstein L, Astbury J, Morse C. Psychosocial and Mental Health Aspects of Women's Health. Geneva: World Health Organization; 1993.
Srivastava A. Marriage as a perceived panacea to mental illness in India: Reality check. Indian J Psychiatry 2013;55(Suppl 2):S239.
Agoramoorthy G. Are women with mental illness & the mentally challenged adequately protected in India? Indian J Med Res 2011;133:552.
] [Full text]
Gajendragad JM. Struggles of women with mental illness. J Humanit Soc Sci 2015;20:37-4.
Pathare S, Nardodkar R, Shields L, Bunders JF, Sagade J. Gender, mental illness and the Hindu Marriage Act, 1955. Indian J Med Ethics 2015;12:7-13.
Paul S, Nadkarni VV. A qualitative study on family acceptance, stigma and discrimination of persons with schizophrenia in an Indian metropolis. Int Soc Work 2017;60:84-99.
Thara R, Kamath S. Women and schizophrenia. Indian J Psychiatry 2015;57(Suppl 2):S246.