|Year : 2016 | Volume
| Issue : 1 | Page : 63-68
Gender issues in psychosocial rehabilitation
Department of Psychiatry, Government Medical College, Thiruvananthapuram, Kerala, India
|Date of Web Publication||17-Feb-2016|
Dr. Suseela Mathew
No. 57 Kakkanadu Lane, Kesavadasapuram, Pattom, Thiruvananthapuram - 695 004, Kerala
Source of Support: None, Conflict of Interest: None
This article is based on my experience in living with mentally unprivileged people in community. This review will be highlighting issues faced by mentally ill female patients, their sufferings, and how the suffering is different from males. Here I share my experience of working with female mentally ill patients and issues faced in their rehabilitation. It should help people in understanding issues involved in female psychosocial rehabilitation and help in planning special rehabilitation services for them.
Keywords: Female, psychosocial, rehabilitation
|How to cite this article:|
Mathew S. Gender issues in psychosocial rehabilitation. Indian J Soc Psychiatry 2016;32:63-8
This article is written based on my experience in living with the socially and mentally unprivileged people in a closed community for 31 years of my life. Such a life in a therapeutic community environment provided me ample opportunity to participate in the psychosocial rehabilitation of those neglected section of society. The community mentioned here based at Kottayam was involved in "community-based rehabilitation" almost 80 years back itself. This community was concerned in the reintegration of children and individuals who are victimized including unwed mothers and abandoned women. In this community, there is a home (Balagram) for the destitute and delinquent children. Some of them were in the street, and many of them came from broken families, disturbed families, parents with a history of alcohol and drug abuse, and families with deprivation and poverty. Some of them were victims of physical and sexual abuse. Here, effort is taken to contact their parents or family members, and psychosocial support is given as far as possible. Many of these inmates are strengthened to bring healthy changes in their families. Life here helped the inmates to feel secure and to get empowered. There are thousands of inmates who after their graduation or higher studies have secured good jobs. Metcalf  writes about this community which was founded in 1934. The teachings of Mahatma Gandhi and Rabindranath Tagore were inspirational in the development of this community.
This community has two colonies where the survivors who have aptitude and interest in agriculture were helped to settle. One is at Kallar in Idukki District, Kerala and the another one is at Attapadi in Palghat District, Kerala. The Government of Kerala had allotted 50 acres of fertile forest land for the settlement of these inmates. This community, along with the support of some volunteer groups, helped the two colonists to construct basements for their homes. No full-time staff from the community was sent to the colonies. However, the members of this community kept visiting them off and on and helped them to sort out problems relating to government loans, procurement of agricultural implements and seeds, marketing, and also the problems relating to interpersonal issues. Gradually, each individual had their own family of procreation. Before long the whole forest area was transformed into a town which was named Balagram. Some of them flourished in such a way that they became wealthy to afford to have their own vehicle in the 70's itself. Majority of them keep in touch with the parent community and pay visits with their individual families.
Rebuilding lives, restoring relationships, and painful issues of forgiveness and restoration were the daily affairs of this community. The life skills which we talk about today were used 80 years back itself in the community. The community members used skills of active listening and positive communication combined with an empathetic attitude and creative thinking to manage the problems on a day to day basis. The caregivers of this community tried to transform the cantankerousness seen in delinquent or victimized inmates into enthusiasm through personal involvement in handling them. Life in the community helped me to realize that victimized or unprivileged individuals, especially women and children are most secure in solid reciprocal relationships.
The mission in rehabilitation and peacebuilding of this community was grounded in the pragmatic realities of daily life which was shared with the inmates. For successful rehabilitation, caregivers have to be role models. To quote the words from a tribute offered by the rehabilitated inmates who gathered at the funeral of the mother of this community "our dearest Kochamma is gone, the mother of thousands of us. She cared for us and nurtured us for the last 60 years. This community helped us to have a normal healthy life. The elders here were our role models. Now many of us are well-settled in different parts of India and outside. The discipline and the vision we learned from here still keep us going, in spite of the trials of life. Appa's and Kochamma's unity as parents has influenced us later in our family life". 
A rehabilitated inmate who is a retired government official who is in his late seventies staying in Kottayam, Kerala writes "Kochamma remains in my heart as an enlightened mother who was always smiling, extending her hands to the needy, and exhibiting welcoming attitude in all her ways." Another ex-inmate who is a retired school headmaster writes "my father was stabbed to death by someone." My mother died of pneumonia when I was a young boy. In this community, I experienced a homely atmosphere and a sense of security. In my life, Kochamma had great influence on me. She smiled sincerely and honestly and gained a place in the hearts of all of us. Her sincere, devoted service and her ability to analyze problems creatively and amicably, contributed to the welfare of the inmates…. Today, when I look back, I realize that I have learned the basic lessons of good parenting from them. Now I am leading a happy and contented family life with my wife and children and other families. Moreover, I am contended with my professional accomplishments as a teacher. Here is the extract of letters written to the parents of the community by a rehabilitated girl who is leading a contented life as a grandmother in Georgia, USA "Appa and Ammachy, your life has always given me the inspiration to love others and to give to others. Always I think of your unconditional love shown to me. I have never seen my mother nor have I tasted the love of my father. However, I got you as my parents who are affectionate and broadminded. The values you shared with me in my life in the community helped me to play the role of a wife, mother, and grandmother effectively". 
My life in the community with inmates who had psychological problems or unhealthy habits gave me opportunities to understand the inner self of the unprivileged section of society. In addition, because of my professional background as a psychosocial therapist several women in distress have come to me for counseling help over the past 30 years. For several years, I had been documenting the life stories of women who were victimized from a mental health professional's perspective. I would like to stress the importance of timely support to those individuals in distress and to emphasize that participation in wider society is essential. In the book "Breaking the Barriers-Towards Women's Empowerment"  it was discussed: (1) How tradition, norms beliefs, and values affect women's role. (2) The power relation between women and men in family, community, and institutions. (3) The possible and potential contribution of women to the well-being and development of society. The responses of a subgroup of victimized women who did not seek help from any source were documented. Common themes emerging out of their responses include (a) negative attitude to life in general which seems to have evolved from a state of helplessness or powerlessness. (b) The impact of social ostracism of victimized women. (c) Ignorance of the available support systems. Because of this, their voices still remain feeble to the enlightened sections of society.
My work with women made me to focus on the various issues of gender. The tool which I have used for community education all these years was skill training and the training methodology was participatory and elicitive in nature. More than 100 training programs on gender sensitization, women's empowerment, and conflict resolution with the involvement and participation of both women and men have been conducted so far. These trainings were conducted in collaboration with various nongovernmental organizations.
| Gender|| |
Understanding gender is essential before discussing about gender sensitization. People are born female and male, but learn to be boys and girls who grow into women and men. They are taught what the appropriate behavior and attitudes roles and activities should be for them and how they should relate to other people. This learned behavior is what makes up gender identity and determines gender roles, which are made to seem natural and the norm. Different societies have different ideas of what it is suitable for men and women to be. Sex is fixed because it refers to the biological difference. Gender roles, on the other hand, change from culture to culture and often change within a culture depending on social and economic factors.
Both men and women are affected by gender injustice. Boys are socialized to deny their feeling and to prove their worth by dominating or competing with others. The constant fear of being dominated by others and of competition makes cooperation and close emotional relationship difficult. In most cultures, power is linked to masculinity. One model of masculinity, which is spreading across cultures, is that of hegemonic masculinity. In this model, man is portrayed as very powerful, always in control, unemotional, and willing to use physical violence in order to achieve his goal. In the case of girls, they are often socialized to deny their intellect and to prove their worth by always placing the needs of others first. Passivity and silently accepting injustice may be seen as signs of femininity. There is no universal model about what is masculine or feminine. In general, however across cultures, what is considered masculine has been valued more and seen as superior to what is considered feminine. In a discussion about gender, often most attention is paid to women and girls. This is because women and girls are the more disadvantaged, marginalized, and they face the higher degree of gender injustice.
The social conditioning determines different perspectives for men and women, and they view different world as well. In the case of men, it is the world of career, cash, success, authority, influence, and public recognition; whereas for women, it is that of love, obedience, sacrifice, tolerance, and family duty. The routine of women's lives makes them to experience more stress than men as they shoulder more number of social roles including that of being a wife, mother, grandmother, daughter, bread winner, and caregiver to all family members. Both the subjective and objective strain appears to be greater in female caregivers. WHO study  gives similar reports. Factors that influence this include differences in role expectations and coping strategies. Women experience and respond to stress quite differently than men. Women often have a tendency toward exaggerated feelings of inadequacy and self-blame. They blame themselves readily for all that goes wrong not only in their lives but also in the lives of their family members-husband, children, and parents. It is the cultural expectation which produces such tendencies. All the institutions of our society reinforce this.
A proper awareness of the issues that affects women at different life stages will help rehabilitation practitioners in planning service measures for female clients. Based on their review of literature in the psychosocial development of women, Caffarella and Olson  identified four major themes:
- The centrality of interpersonal relationships in the self-concept of women across all ages
- The importance of social roles in directing women's lives
- The nonlinearity of women's lives as they traverse various roles
- The changing development issues that women face as they mature and age.
Women, in general, are more likely to live with a number of factors that put them at a significant disadvantage in their later years. These factors include widowhood, financial insecurity, increased risk of poverty, and inadequate social support and health care.
| Gender Violence|| |
Gender violence is not a women's issue, it is everyone's issue. In most society, women are considered less important than men. This has resulted in great inequalities between men and women and a high level of violence and discrimination against women. One of the most common forms of violence across the world is violence against women and girls. This is not always recognized as violence because it often takes place in the private sphere of the home. Violence against women within the family or within the general community includes sexual harassment and abuse, rape, forced prostitution, and violence perpetrated or condoned by the state. In a society like ours, which is tradition bound and male dominated, women are confined to domestic servitude; her movements are restricted and are given no freedom to have personal choices. She merges her identity with that of her spouse and gradually perceives herself as a subordinate person. The imposition of restriction begins in the family of orientation which eventually helps her to adjust passively with the family of procreation. Despite the women's subdued position in the family, she is facing various types of violence - physical, psychological, sexual, and intellectual. Incidence of sexual assault and rape is reported to be on an increase. Mullen et al.  in their study reported that women's experiences of difficulties in their sexual relationships range from communication problems to severe physical and sexual abuse, which increase their vulnerability to psychiatric disorder. Many women are victims of violence in their own homes. The very same person who is supposed to be her "protector" is turning to be the perpetrator of violence behind the closed doors. This may be viewed as a custodial violence. All these violence have to be recognized as human rights issue because all these are the manifestations of the violation of the fundamental rights of women.
In our country, the Protection of Women from Domestic Violence Act 2005 has been enacted. However, gender discrimination and any type of oppressive practice cannot be removed by legislation alone, but require active participation of all right thinking people. Professionals in the psychosocial rehabilitation field have a clear and responsible role in this.
The mental health problems of gender violence victims who normally do not seek psychiatric help is getting visibility and is causing to widen the boundaries of the mental health system. Mowbray et al.  discussed about this. Women who are victims of sexual assault or rape face societal stigma and are often viewed as being sexually promiscuous, and lustful. This overlooked section of victims not only illustrates inadequacy in mental health services but also reflects societal stereotypes. Studies like that of Stark et al.  revealed that the health care system has to play a proactive role generally are unresponsive to the women victims of gender violence. A woman seeking medical help for physical injuries or pain would be treated symptomatically, even when she makes several visits for recurrent injuries or pain. Instead of probing into the possibilities for domestic violence she would be viewed as a "problem patient."
| Working with Victims of Gender Violence|| |
One of the most painful aspects in working with victimized women is encountering the feeling of abandonment these people carry. Our task in helping them recover from this state has 2-fold thrusts. One is spending time with such persons and empathizing with their experience (support). The other is helping them to become equipped (skill building) to manage and contain the abandonment through relevant activities that life requires. Having specific tasks to focus on can be a powerful tool against the discouraging thoughts, feelings, and somatic complaints. Neuwen  explains this as "working around the Abyss." There must be dynamic moving back and forth between supporting and skill building.
While dealing with the problems of women, family intervention often reveals that the issue which is presented has a connection to a strained relationship with the spouse or past instances of sexual coercion or assault by any one family member. Such abusive relationships can lead to psychological and social damage not only to the individuals involved but also to their children. Studies have proved that children of abused women develop delinquent and later anti-social traits. Early interventions can prevent the huge social damage and cost incurred in correctional services. Both women and men would benefit from "gender sensitization" and "conflict resolution" trainings. They get help in resolving their conflicts without the escalation of the problems. These training help women learn skills to take control of their lives and to be responsible for finding their own space. This means transforming their silence to constructive verbal expression of their needs and preferences. The characteristics of women like supportive, listening, self-disclosure, and respect for other's needs, patience, and tolerance are often viewed as weakness. Men have to be sensitive to this and help women to build on their strengths. The skill building imparted through these trainings which I have conducted, especially "empathy training" for men and "assertive training" for women were found to be effective. The evaluation reports received from participants of above mentioned trainings reveal this. A study by Barrie  gave a similar report. Women need opportunities to connect with each other, to realize the commonality of their difficulties and joys. Sharing personal experiences and hopes would help to move forward toward progress and growth. This method has been found to be successful and can be made possible through the participatory and elicitive methodology in training programs. To leave an ongoing abusive relationship, a woman requires inner strength and also skills necessary to earn a livelihood. For this, she needs transitional support from the family or from community service programs. Such timely supports would help her to lead an independent and responsible living.
| Gender and the Impact of Mental Illness|| |
In my observation, the impact of mental illness on women and men are different because of their different social responsibilities and societal expectations. As rightly pointed out by Worrell,  traditional psychiatric services which were based on a medical disease model have often failed to accommodate individual's needs based on gender. Many of the symptoms associated with childhood abuse put women at heightened risk for re-victimization as adults. For women, a psychiatric episode may be directly produced by current experiences of physical or sexual or verbal abuse. Despite high prevalence rates, various studies report that mental health professionals seldom explore histories of current or past abuse faced by women with psychiatric illness. Failure to do so would contribute to ignoring important issues essential to women's recovery process in treatment and rehabilitation. ,,,
| Gender and Rehabilitation|| |
The overall awareness and significance of issues pertaining to women's mental health have been studied and reported over the past two decades. The prevalence of the perceived sex differences in mental disorder is reported as the result from interaction from many diverse causes including environmental, hormonal, genetic, and social factors. The study by Lewis-Hall et al.  highlighted this aspect. Further studies have reported that these sex differences appear to exist not only in their etiology or progression of a disorder, but also in the response to intervention. In planning rehabilitation measures for women, the knowledge and skills to address their specific needs like those associated with reproduction, parenting, safety, and privacy are crucial. Sexual harassment and assault are a general risk in institutions caring for psychiatric patients. This has been pointed out in the WHO Resource Book 2005. 
Mental disorders have been linked with alienation, dependence, and poverty, especially in the Indian situation. These conditions are more frequently experienced by women as a result of multiple factors. Study reports reveal that among people who had psychiatric problems, more women than men got married. These marriages took place because of substantial dowry offered for women. However, more married women than men were deserted, abandoned, or divorced. In addition, many of them had to face physical abuse and violence from husbands prior to separation. In contrast, majority of men who got married were cared for and financially supported by their wives. A study by SCARF  reported this. The onset of serious mental disorder in women usually occurs in early adulthood and studies have pointed out that the normal development and maintenance of social roles such as sibling, spouse, and parent may be interrupted and are often irretrievably scarred.  The damage that happened to their relationships earlier in life had resulted in retarded development of relationships and reduced social support later in life. During the illness phase, mostly women are sent to their family of origin; though they do not have any claim there. Even after recovery, they have to face the ongoing threat of divorce either from husband or from the in-laws. Later in life, children may reject or disown them, when these grown up children face social stigma. Such situations of insecurity, uncertainty, and social ostracism would make their state all the more difficult later in life to cope with the aging experience. A study by stromwall and Robinson  gave a similar report.
| The Strength of Psychosocial Rehabilitation Model|| |
Psychosocial rehabilitation model (PSR) is a facilitatory model, a "doing with" as opposed to "doing for" or "doing to." There has to be a recovery milieu for mentally ill victimized women and men. Individual's strengths and resources have to be identified and encouraged. This would be empowering for them. It can transform their state of helplessness and powerlessness to be a challenge. A supportive rehabilitation team is necessary to understand the complexity of the mentally ill/traumatized person's inner and outer worlds. Modeling healthy human functioning within the helping team will gradually be internalized to improve the functioning and resilience of the individual's inner world. The rehabilitation practitioners have to look for opportunities to reframe problems into separate issues which can be handled. Hopelessness is always a struggle for the person. They will need to lean on the hope and faith of the helping person/team. The rehabilitation team members, in turn, have to be supportive to each other to encourage hope. Their positive attitude can be an antidote for the despair the person experiences.
Our existing rehabilitation approaches need review and enhancement to be appropriate for both women and men. Areas of skill training and the development of environmental resources and supports have to be addressed while planning for the rehabilitation of women who are victimized or mentally ill; we have to focus on recovery, independence, and empowerment. This would enhance the process of breaking the cycle of residual disability, marginalization, unemployment, and poverty. The stages of rehabilitation service for these women are:
- Enabling them to achieve an effective recovery through strengthening social support and locating safe shelters
- Enhancing their economic independence through rehabilitation counseling, vocational training, job placement, and job support
- Empowering them to make the transition in an effective way from institutions back into the community. This is possible only through skill building, awareness programs, and networking.
Identifying and responding to the needs of female and male clients gives the professionals opportunity to reflect on and monitor their congruence with major PSR values and goals. Pratt et al.  gave a description about the values and goals. The PSR values are self-determination, dignity and worth of every individual, optimism, capacity of every individual to learn and grow, and cultural sensitivity.
| The Goals of Psychosocial Rehabilitation|| |
The goals that guide psychosocial rehabilitation serve to define the vision and mission of rehabilitation programs. Several researchers in the field discussed elaborately on this. ,, After reviewing several studies to identify the rehabilitation goals and values including the one by IAPSRS 1996, Pratt et al.  suggested that there was near universal agreement on three goals of PSR: Recovery, community integration, and quality of life. In our Indian context, few more goals are also important such as inclusiveness, opportunity, independence, and empowerment.
It would be worthwhile to clarify the two keywords recovery and empowerment.
This means learning to accept the boundaries that the disorder has played upon life and to realize that most of the experiences that define essential humankind are still attainable even within these boundaries. The concept of recovery reveals the positive focus of PSR which reflects an individual's possibilities rather than his/her limitations. Bachrach  discussed this in detail.
This is the process of increasing the assets and capabilities of individuals or groups to make purposive choices and to transform those choices into desired actions and outcome. Stone  defined the term empowerment as being composed of three elements: (a) Self-esteem and self-efficacy combined with optimism and a sense of control over the future. (b) Possession of actual power. (c) Righteous anger and community activism. Corrigan et al.  have distinguished two dimensions to empowerment: Self-empowerment and community empowerment. The former is where the low self-esteem that results from gender bias and stigma is replaced by a sense of personal honor that affirms control in one's own life. Community empowerment is where the individual confidently addresses public barriers in accomplishing life goals. In one of the World Bank reports, empowerment is explained as full autonomy on two levels - individual and collective (level of society). According to Sen et al.,  empowerment was about changing power relations. Wallerstein  reported that a meta-analysis of 40 women's empowerment projects showed a wide range of quality of life improvements. His review concluded that improved education for women had clear positive effects for children's health, while income in women's hands will result in better family nutrition and health. But for women's potential to be realized to the maximum requires an increase in autonomy, mobility, decision making, authority, control, and power within the household. What is needed clearly now is that empowerment and gender mainstreaming should reflect in policy structures and focus on power relations between women and men.
The combination of the goals and values of PSR helps us to determine the guiding principles. Twelve principles discussed by Pratt et al.  include:
- Individualization of all services
- Maximum client involvement, preference, and choice
- Partnership between service provider and recipient
- Normalized community-based services
- Focus on strengths
- Situational assessment and not overall assessment
- Holistic approach - Treatment/rehabilitation integration (complementary endeavors)
- Ongoing, accessible, coordinated services
- Vocational focus
- Skills training
- Environmental modification and supports
- Partnership with the family.
A review of the current psychosocial rehabilitation programs wearing our gender glasses is worthwhile to ensure optimum effectiveness.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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