Help mentally ill patients get access to healthcare by The Banyan

We had to adapt to new ways of working and recalibrate for a painfully altered world. We set up a quarantine or holding centre to continue to be able to bring in new clients into our ECRCs. We kept our outpatient clinics open, door delivered medicine where needed, strengthened aftercare to prevent recurrence of illness due to increasing impoverishment. Also, we ramped up our outreach and social entitlements program as people’s livelihoods stood destroyed. They needed support for basic day-to-day survival.

During a lockdown, the homeless had no doors to shelter behind. No reserves to last beyond the next meal. No petty shops or roadside food stalls to offer food on credit or out of kindness. No temple, gurudwara or church serving free meals. No passers-by to beg a few rupees off. And on those ghost streets roamed a far more vulnerable cohort – a bewildered host of homeless people living with mental illness, and with far less capability to make sense of this frightening new reality

Mrs. Kala is a native of Panagattupakkam village in Tamil Nadu. she belongs to the marginalized Irular community. Irulars are daily wagers. Originally, their profession revolved around animal hunting, honey collection, fishing and farming. Kala did not study beyond middle school and later married a man her parents did not accept. She and her husband moved to a town where they struggled. But he soon died of an illness. Devastated, Kala went back to her village. Shortly after, she got remarried to someone her parents approved. Still very much financially strapped, Kala worked as a daily wager in fields owned by the upper class to support her children. She had to work long hours but earned low wages and zero respect. She tried to get her children admitted to local schools, but was denied admission as she could not provide supporting identity documents. She did not know what to do. It was around this time that The Banyan’s NALAM team met Kala. The team explained the process of procuring social entitlements and documents and assured support for her through this process. That’s also when the pandemic hit. Apart from the social entitlements that The Banyan facilitated, Kala also received allowances to make ends meet during the pandemic. When she received her children’s documents (birth certificate, Aadhar card, and ration card), her joy knew no bounds. Just like any parent, Kala wished her children to be in a better position. This was the first step. Encouraged by the success, she asked the NALAM team about the process of procuring these documents. She knew there were many women and children in her community who, at some point, was as helpless as she was. So Kala decided to step up for the sake of her community. With support from NALAM workers, she started educating the women in her community. Today, Kala has travelled miles from her earlier helplessness and is working to ensure women in her community are independent and empowered.

The year 2020-21 was crucial for The Banyan in terms of aligning strategic collaborations that further advanced health, social wellbeing and inclusion among homeless people with psychosocial disabilities. Change and growth has been a constant because we keep the vulnerable population we serve as our central focus and have from them learnt the importance of grit, introspection, courage and empathy. The Banyan continued to draw from its experiences and established a range of approaches that enabled a future filled with positive destinies and outcomes for its consumers. We explored the link between homelessness and mental illness and collectively agreed on guidelines that strengthened alliances across domains of research, practice and advocacy.

One among our three core approaches, the Emergency Care and Recovery Centre (ECRC) was taken to scale in Tamil Nadu and Kerala with state support. In the previous year we partnered with the National Health Mission, The Government of Tamil Nadu to operationalise emergency care and recovery services catering to homeless people. This was extended in 2019 by collaborating with the Government of Kerala to set up an Emergency Care and Recovery Centre at Guruvayur. Services in these centres drew from co-produced value boards, program goals and processes. Relationships were resolutely forged at both domain and policy level to furtively and effectively scale up solutions. As always intersectoral linkages with Grassroot Organisations, Panchayat Leaders and Community Members proved indispensable in persevering and diffusing essential care.

Our sustained efforts have always been in the anticipation to envelop the limitations of the archetype medical model and demonstratively reorient care paradigms in public mental health systems. Post the directive passed by the Supreme Court to establish long-term exit pathways for people in state mental hospitals, we made strides in designating tasks and resources towards the same. It has been especially gratifying to see incremental progress being made to scale up inclusive living options in Tamil Nadu, Kerala and Maharashtra these past few years.

Partnerships with State Governments have helped us co-opt and uptake approaches to care. Engagement with the Government of Maharashtra this year facilitated the replication of Home Again (HA) for long stay cohorts from state-run mental hospitals in Ratnagiri and Thane. Over the years, HA has enabled individuals to pursue independent, atypical and transformative lives of their own choice with local community support. A National Study which consolidated surveys of service users across 43 state psychiatric hospitals and recommended strategies for community inclusion (commissioned by The Hans Foundation and anchored primarily by The Banyan along with other civil society partners) was officially released for wider dissemination. The reportage is expected to reform government policy, shift attitudes away from long-term institutionalisation and towards community driven inclusiveness.

Emergency Care and Recovery Centre

Thematic Areas of Engagement Across Projects

The ECRC building is divided into two sections:

Emergency Center: with a Helpline for homeless women offering crisis intervention, primary care department (that coordinates basic needs fulfillment such as clothes etc) amd acute care beds

Recovery Hub: with skills development and employment services, built environments and modules for pre-discharge and recovery, support groups, and reintegration and aftercare services
Medical and psychiatric interventions, social interventions and psychological therapies for acute care and recovery are offered across both sections. Since inception in 1993, the ECRC has offered services to 2000 homeless women with mental illness. 75% of women who have used the services have recovered and journeyed back to their homes and families of origin. With multidisciplinary practice and an unwavering pursuit of social recovery goals such as return to work, social roles in family etc, women on an average spend only 92 days within the ECRC before making a choice of pathway to exit the institutional facility. 60% of reintegrated women in the last five years remain in continued care to assist them in sustaining their recovery and prevent a lapse back into homelessness.

Critical Time Care: Over the last 26 years, 1924 people with mental illness have received critical care interventions and 1468 have been reintegrated until now (which translates into 76.29 percentage). In this period, using case management as a critical method in care coordination, the 100 individuals living in ECRC were provided crisis intervention services, basic needs of quality food and clothing, a safe environment to live, health interventions including psychiatric, psychological therapies, social and rehabilitative interventions such as work, legal aid, housing, socialisation, ​reintegration​​ and​​ aftercare ​​options​.

Community re-entry: Reintegration options for service users were facilitated, with locations of return being across Tamil Nadu and beyond. Between February to March 2020, users with prospects for reintegration attended pre - discharge hubs for a period of 8 to 12 weeks based on individual needs matched across other pre-set indicators. The hub enables incremental pathways towards skill development, employment, home and community-based skills, associated ways of being and other domains of care to develop.

Continued Care Services: Apart from this, the period saw new enrolments into aftercare services. They were connected to needed follow up services (OP Facility, Social Security, Postal Medication and Phone Follow Up). On a larger level, 228 users are engaged with our clinical and social support services through Aftercare. Users interacted with their possible carers (family members) and familiarised themselves to what they may expect back home. Families were traced by accessing local networks and other surrounding coordinates of care, which allowed for bidirectional relationships with recovery domains to be maintained. Concerns if any were discussed with a team of multidisciplinary team of psychiatrists and social workers and appropriate solutions are worked towards. This meant confronting and acknowledging intimate and adverse histories, changing relationship and family dynamics, social and economic disadvantages, lopsided care burdens, neighbourhood stigma, livelihood options and other thematic concerns in the context of mental illness and wellbeing in the community.

Skills and Social enterprises: We also connected users to employers on completion of which they can pursue related livelihood through our employment kiosks. These are work options which are optimally located near residences of users and based on interest as well allowing them to pursue without any major barriers. Before attaching users to employers (who are previously vetted), there are also debriefs conducted to clarify mutual expectations.
Across sites, 431 users are engaged in Skills Training and 37% are engaged in full time employment, external and internal. In this period for instance, more than 30 users from ECRC identify as employed earning an average income of INR 3000. 36 users trained in some sort of skill or vocation earning an average incentive of INR 500. Residents were encouraged to define their aspirations, routines and pursuits. These user directed efforts form an important priority of the intervention. Apart from offering decent pay and engagement, these jobs allow the opportunity to handle responsibilities, converse and gain personal meaning and agency intertwined with recovery. These jobs have been co-solicited by the clients based on their choice and offer them the opportunity to pursue self-directed recovery goals. It also paved the way for participation in activities such as shopping, money management and innovation amongst users.

Care and support being provided

Program Update

Poor and homeless women don't wonder what will I have for dinner today? Instead, they ask themselves, Will I eat today? Serving a nutritious food everyday at The Banyan provide critical healthy dinners to hundreds of poor and mentally ill destitute homeless women every day.

During their time on the streets, many of our clients have gone days without a meal. Others have had to resort to rummaging through garbage and waste, in order to survive. It is no wonder that most of our clients have chronic malnutrition and anaemia at the time of their admission.

At The Banyan, the menu is designed and implemented after taking into consideration various factors, including regional palate, taste, and flavours. Menu diversity is achieved by using a wide variety of seasonal vegetables and locally available ingredients. We have adopted a cyclic approach with preference to local palate. We also mitigate chronic nutritional deficits by providing milk and Egg that is healthy and nutritious.

This program supports the doctor's fees who look after the residents health regularly and the costs of the psychiatric, General medicines and the hospitalisation expenses. Through this program, At any given point of time, there are 300 homeless persons with mental health issues residing at all our projects.

Story from the field

Resources are a matter of concern - there are detrimental consequences that may need to be faced if users develop dependence attachments only to the organisation. We encourage users to draw from the community around them and form personal relationships that help in sustaining recovery beyond remits of institutional care and without any impasse. Durga is an aftercare user, who lives alone in a secure neighbourhood, her needs are taken care by her daughter. Things were going well and there were no obvious concerns that needed addressal. However one day, Durga sent a letter to the organisation, requesting that her allowance be increased, because she felt immense guilt and a certain amount of shame that it was her daughter who was supporting her monetarily. We made basic enquiries and it was revealed by the daughter that this was not true and that she was willing to support her mother through her life, and caring for her mother did not impact the daughter in any way feared by Durga either. A bit of background on Durga - Durga has never known a life which was sans work. She used to take up any and all roles that were offered in order to supplement the family’s income and push it through the cracks that were starting to appear. What she was suffering was the lack of social sanction the last few years. We connected her to our skills and employment cell, who in turn set her up with certain vocational pursuits she could engage herself in. Durga took it up readily and now earns decent money as well as the respect she craved for.

Program Update

During their time on the streets, many of the clients of the Banyan have gone days without a meal. Others have had to resort to rummaging through garbage and waste, in order to survive. It is no wonder that most of the clients have chronic malnutrition and aemia at the time of their admission.

Meals at The Banyan go well beyond the basics. Not only does Banyan provide freshly cooked meals that are tailored to the diverse cultural roots of the people they serve, but they also mitigate chronic nutritiol deficits by providing food that is healthy and nutritious.

This program supports the doctor's fees who look after the residents health regularly.

At any given point of time, there are 125 homeless persons with mental health issues residing at the ECRC programme.

Story from the field

Kagavalli is caregiver of the client Sundari accessing KKgar OPD. Sundari has a son who is studying diploma. Sundari developed psychosis during pregncy and tried to commit suicide by jumping from first floor. Though she survived, her mobility was affected. She gave birth, and her husband abandoned her. Her mother Kagavalli was also deserted by her husband who was an alcoholic. Kagavalli struggled to make ends meet. Her daughter's ill health and the growing demand of her grandson’s health, nourishment and education was bothering her, but she did not give up. She started making iddlies and sold them. Though she had grinders given by late Chief Minister Jayalalitha, floods destroyed it. She was not deterred, she used to make lunch to her house owner and so she raised money for paying rent. Her daughter was epileptic too, if Kagavalli wasn’t at the house, Sundari would put her excreta on plate meant for eating. The caregiver moved from earth and heaven to earn her livelihood. She made vaththal and sold. At The Banyan, she was taught to make jewellery out of quilling paper and textile printing, fashion jewellery, terracotta jewellery. The Banyan recommended scholarship for her grandson’s studies from another NGO. The grandson grew up hating his mother. This was addressed by The Banyan and the boy attended meetings and started to understand his mother’s condition to the extent that he started taking care of his mother. Kagavalli sold vaththal and jewellery. The Banyan sold her things in their stalls. Kagavalli started to teach youngsters jewellery made out of quailing paper, terracotta and beads and she was not worried that her enterprise was going as a sil’s gallop; she knew eventually she will become busy. She started posting in Facebook and now her orders are increasing. In December month she was referred by The Banyan to a lady who had come down from US to make necklaces so that the lady can sell it in America. As Kangavalli’s efforts have borne fruit, she has a beaming face as she moves on with her life.