|AWARD PAPER: BALINT AWARD PAPER
|Year : 2016 | Volume
| Issue : 2 | Page : 83-91
Psychosocial issues in an unknown mentally ill: The journey to discover professional self-actualization and more…
Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India
|Date of Web Publication||25-Apr-2016|
Department of Psychiatry, Government Medical College and Hospital, Sector 32, Chandigarh - 160 030
Source of Support: None, Conflict of Interest: None
This case describes my journey with a homeless mentally ill patient who was suffering with schizophrenia, and how it taught me what chronic mental illness means and what kind of social issues are associated with mental illnesses. It has also given me new insights into the community rehabilitation of unknown mentally ill persons; which I have tried to demonstrate through my real-life experiences of working with two sisters suffering with schizophrenia.
Keywords: Chronic, homeless, mentally ill, self-actualization
|How to cite this article:|
Tyagi S. Psychosocial issues in an unknown mentally ill: The journey to discover professional self-actualization and more…. Indian J Soc Psychiatry 2016;32:83-91
|How to cite this URL:|
Tyagi S. Psychosocial issues in an unknown mentally ill: The journey to discover professional self-actualization and more…. Indian J Soc Psychiatry [serial online] 2016 [cited 2020 Jan 20];32:83-91. Available from: http://www.indjsp.org/text.asp?2016/32/2/83/181091
| My Introduction|| |
My professional journey started in the year 2002 when I took admission in the Masters in Social Work (MSW) course; the initial part was spent in training until 2006. Throughout my training, I repeatedly imbibed that “psychiatric social work (PSW)” was a professional service and that a person taking up this profession should have the following virtues - respect for human personality, dignity for each human being, matching resources with needs, stimulating change calculated to enhance democratic value, accomplishing change through cooperation on both intellectual and emotional levels and serving as a change agent from behind the scene. While choosing my field, I made a conscious choice to take up PSW as my specialization (contrary to the popular choice of industrial social work among students due to it being more rewarding in monetary terms) while I was doing MSW as I realized that many of the qualities required to become a professional psychiatric social worker were probably innate in my personality.
I got the opportunity to potentially put into practice my skills learned during the many years of training as a psychiatric social worker. I joined one of the most premier institutes in the country (PGIMER, Chandigarh) on a regular post of Medical Social Worker. However, within 2 months, I realized that I was not doing what had been taught to me during my training at Central Institute of Psychiatry  like rehabilitation, group therapy, family interventions and family therapy, self-help group development, psychoeducation, guidance, counseling, etc., or is being done at NIMHANS  (psychosocial assessment and intervention of patients and families, home visits for diagnostic and therapeutic services, community agencies contacts for resource mobilization, marital and family therapy, group therapy, liaison services, training paraprofessionals and nonprofessionals, extension services such as camps and outreach programs); centers where PSW as a profession emerged and excelled. I was handling work, which was not in keeping with what a psychiatric social worker will generally carry out. Having trained differently to work in a psychiatric setting, I soon started feeling disenchanted with my work profile although I had to reconcile to it as it was in keeping with job description of the post at which I had joined.
A breakthrough in my professional journey came when I joined the Department of Psychiatry, Medical College and Hospital, Chandigarh as Assistant Professor (PSW) in March 2013, and got my first case to handle in that capacity.
| The Case (Miss G)|| |
A 62-yesr-old female, G, was admitted to the psychiatry ward as an unknown patient. Before admission, she was staying on the road side at the railway station and survived by begging. At the time of admission, she was unkempt and untidy, was seen muttering to self, had incoherent and irrelevant speech, and lack of insight. After assessment, patient was diagnosed as suffering with schizophrenia, and she was started on antipsychotic medication (Risperidone) by the treating psychiatrist. Within 2 weeks, the patient started improving and providing details about her personal life. She informed me that she had a house in Chandigarh, which was occupied by her younger sister who was also suffering from a psychiatric illness. She also gave addresses and phone numbers of couple of well-known and influential persons in Chandigarh. She claimed that they are her relatives. During the ward discussion, when the treating team shared this information, almost everybody (including me) felt that her claims of having a house in Chandigarh (which is a dream for many local residents, in view of high cost of property) and her assertion that she is related to many known persons in the city is part of her psychopathology. However, there was only one person who could feel some truth in her claim, and that was my HOD. When he asked me to verify the information, I could not say no but was simultaneously feeling, “what a waste of time, a patient who has mental illness and has been talking irrelevantly, why should the HOD believe that there could be truth in her statements?” However, being a junior colleague, I could not say no and reluctantly agreed; more so to prove myself right.
Following this referral, my immediate thought was that her high claims could be part of her grandiosity. In addition to verification of information provided by her, another reason for referral was to plan about her discharge and postdischarge rehabilitation. Since she had been brought from the roadside, sending her back onto the streets was definitely not the desired method of discharge. However, as she was improving fast, there was pressure on me to act fast due to shortage of beds in the ward with the average stay being 14–15 days and the HOD not taking kindly to long stay patients.
At this time, it was hardly a month since I had joined as Assistant Professor (PSW) in the department with practically no prior experience in the field of rehabilitation. Hence, it was a massive challenge to accept this “uphill task.”
I started my task with verification of the persons whom G claimed she knew. To my utter surprise, not even a single phone/mobile number provided by her was wrong; additionally, I also discovered that all the addresses provided were correct. This jolted my concept of schizophrenia. I asked myself, “how can a lady suffering with schizophrenia, staying on roadside and surviving through begging be so accurate? Even a normal person at the age of 62 years is not expected to have such a sharp memory of phone numbers and addresses. Over the years of my training and otherwise, I have learned and understood that patients with chronic schizophrenia suffer from cognitive deficits. I asked myself, “is she feigning?” However, “I could not dare challenge the decision of the ward team and quietly challenged my thought; though that did add to my inner turmoil.”
Although the names and addresses of the persons given by her were correct, majority refused to acknowledge her and bluntly told that they had never heard about such a lady. This made me confused. The dilemma for me was to decide who was right and who was wrong. I asked myself,” if the name and address was correct, then how could it happen that they did not recognize her.” I again started getting a doubt that my patient was wrong. However, another thought was compelling me to try further. I told myself that their refusal to recognize her could be a part of social stigma. The angry and blunt reply by some of them made me suspicious that they are denying, otherwise, why they should get upset after hearing her name. I accepted the challenge and decided to make more efforts.
I made a list of persons and places for paying home visits which included her house in Chandigarh, relatives/friends whom she claimed to know, school which she claimed is being run by her cousin, Post Office where she claimed to have her account, school where she claimed to be teacher, and Office of State Legal Services Authority (SLSA) where she claimed the papers of house and will of her father were available.
In addition to the above mentioned information, she claimed that she was married and gave the telephone number of her husband. When I called him, he was very reluctant to talk, but on persuasion agreed that they got married in 2004 and he had 2 children from his previous marriage. He told that patient was well-behaved at the time of marriage and used to cook, took care of household chores till the year 2007. According to him, she used to take some medicine for her sleep disturbances and there was no problem in their marital and sexual life till 2007. After 2007, she gradually started developing problems and started talking irrelevantly and behaved abnormally. She came to live with her father in 2010 and never went back to her husband's house. He further informed me that in the year 2010, after her father expired, both of them (patient and her husband) gave in writing, in the presence of a judge that both did not want to live together and will not have any share in each other's property. I got some relief and started getting a feel that the other information provided by her might also be true.
Later, during another visit, it was confirmed that the patient used to work earlier as teacher in a reputed private school of Chandigarh till 1987. The information was correct, but no one could provide any further details regarding her illness. Further, it was verified from the Post Office that her father had an account and she was a nominee. However, she could not take out the money because for operating the account, the Post Office required death certificate of patient's father and two persons with their identity card who could identify her.
I further came to know that patient's father had a lot of good will in the society, and he was very affectionate towards both his daughters. Maybe he knew that his son will not take care of his two sisters. Hence, well in advance, he had divided all his property among his two daughters in his WILL. In addition to a house in Chandigarh, he tried to have a joint bank balance in the name of both the daughters. I was touched by the affection and concern of a father toward his daughters, including the display of future planning after his death.
After this, my conviction to help her increased further. My immediate challenge was the fact that she had no primary/secondary social support, and though tertiary support was available, she was unable to utilize it due to her mental illness. When I reached her home, I was shocked to see the condition of her house and her sister. Her sister “S” was shouting inside and refused to open the door. The neighbors told me that she does not allow anybody to enter her house, and she was labeled as “mad.” I came back and decided to take further details from my patient. “G” told me that her sister had been suffering from mental illness for last 20 years, and she had been on treatment from the same department. The information provided by her was true and we were able to trace out her sister's case file.
It looked strange to me that despite having a house, why had G been living on the roadside. On further inquiry, she told that she had left the house as her sister would fight with her a lot, did not allow her to use T.V., cooler, fan, gas etc., which made it difficult for her to stay under one roof. The confirmation of the fact that G had a house in Chandigarh gave me relief that she had a place to go to following discharge. “After all, she had equal share in the house.” However, my brief interaction with her sister and the detailed account given by the neighbors made me equally convinced that her sister will not allow her to stay with her. The pressure of discharge was building on me as GK was showing faster recovery and became complaint to medication. I was nowhere near to a solution for discharge!!!
I kept on thinking about the possible solution. The immediate thought came to my mind, “why can't I bring her sister for treatment and send the patient home?” However, both the things should happen simultaneously. My thought took the shape of decision, which was later approved by her treating psychiatrist (HOD).
| The Dilemma so Faced and My “Conflict”|| |
However, I realized that taking such a decision was easier than getting it implemented. Her sister was not allowing anybody to enter her house. After going through the Mental Health Act (MHA) 1987, I thought of admitting her as involuntary patient on the request of her neighbors who had earlier reported that they were disturbed by her behavior. I discussed the idea with them and informed them that G had shown excellent improvement, and she is ready for discharge. However, when I asked them to write a letter to the local SHO (police) regarding her sister's admission, no one came forward. We as the treating team knew that the discharge of G and the admission of S needed to coincide; otherwise, the improvement achieved with G will go in vain. However, we had no clue how to get S admitted.
I along with the HOD-cum-treating psychiatrist pondered repeatedly if without any social support and few residual symptoms will G be able to manage herself, her household and her sister (who also had schizophrenia and was not on medication). During discussions, we also felt that life would have been very stressful for any male/female in such circumstances even if he/she did not have any psychiatric disorder. Hence, is it a judicious decision on our part to think of community living for both G and her sister, or is it just a dream?
My HOD was telling me time and again that there is strong possibility that we would be able to ensure community living for both of them. Although such discussions gave me courage to go ahead, the road ahead realistically was not only bumpy but also looked blocked. He would boost my efforts and share his experience of working in Australia where he had seen such patients being managed entirely by case managers (psychiatric social workers) and was of the opinion that we should try the same here with these two sisters. He felt that both the sisters would be able to live amicably under one roof. I, however, knowing the limitations of the case disagreed internally. On the other hand, I had confidence in the years of experience he had and thus started working toward the goals outlined, which (at that moment) I felt were unattainable and beyond the scope of mental health professionals. To be honest, at that time the thought that his expectations were unrealistic would haunt me frequently.
New facets in the case kept on unfolding after every few days, weeks and months and it became a never ending journey for me both professionally and personally, where boundaries got blurred and despite the fact that I was aware that it is happening, I could do nothing about it. Here, I would also like to mention that in the department I was looking after three services Home Based Treatment (HBT) Services, Mental Health Cell (which was created to carry out the functions of Chandigarh Mental Health Authority), and Vocational Training Unit of Disability Assessment and Rehabilitation and Treatment (DART) Services. With little hope internally, and under pressure and expectations from my HOD, I began working with two chronic patients with schizophrenia having disability who were biologically related, having their own house in Chandigarh, were surviving as beggars (one staying at railway station), were not ready to accept treatment, having no one to look after for them at any time (crisis or even in routine)!
| ”Her Sister” as the Confounding Aspect|| |
With this background, coming now on to “S”! As the neighbors refused to help, I started exploring other means of admitting her. Since these amounted to special circumstance where there was no relative or friend to make an application, I tried to utilize Section 25 and Section 21 of MHA, 1987.
Under Section 25, a police officer in charge of police station may take a person into protection and produce before the magistrate for treatment provided: (i) Any person found wandering at large within the limits of his station whom he believed to be incapable of taking care of himself, or who is dangerous to others. However, not unsurprisingly, police failed to provide any help. Police wanted in writing from her neighbors that she is dangerous, but no one was willing to come forward. I felt a little demoralized (again!… a feeling I was getting used to on a regular basis now) as either public or the police had no time or obligation to give much heed to this issue of helping people with mental illnesses.
I again consulted the MHA Manual (1987); Section 21 (admission of mentally ill persons under certain special circumstances), which says that if a patient is unwilling for admission, he/she can be admitted to a hospital on the application of a relative or a friend and if the medical practitioner is satisfied, the patient can be admitted on the basis of two medical certificates for a period of 90 days. As G was medically stable and well, the treating team was able to declare G fit and took an application from her regarding admission of her sister into the hospital and on the basis of her application, her sister was admitted under Section 21.
I ensured (through HBT Services) that discharge of G and admission of her sister S happened the same day (with a difference of only few hours). I was a bit relived with this 'achievement' though had not contemplated what all was yet to follow.
| Miss G Again!|| |
The next immediate thing to be taken care for G was to find the source of money for her daily needs and ensuring that she remained compliant and followed up regularly in outpatient department OPD. HBT team was given the responsibility of visiting her daily and to ensure compliance by checking the medication strips and follow-up in OPD. At that time, HBT Services had just been initiated and were running under resource and logistic constraints (without dedicated vehicle, manpower, etc.). However, feedback from HBT about G was very pessimistic, as immediately after her discharge she stopped complying with whatever was told to her during predischarge counseling (which had been done over three sessions). She would go out of her house early morning, and would not return home till 5 pm as she knew that HBT Services operate only during official hours (9 am to 5.00 pm). If per chance, HBT team met her at home she would talk very rudely with them, telling that she did not want any help from the hospital or from them and would say that she was not suffering from any mental disorder and in case of any need she can consult a private physician. Gradually within weeks of her discharge, my experience made me think that this all was outside the preview of psychiatric social worker's duties and even the members of HBT who were assisting me almost revolted and said. “We cannot run after her and are not ready to bear all the insult she does publically.” Being in-charge of the HBT Service, I tried my level best to keep their motivation alive by trying to show them the nobility involved in the case, telling them that it is a unique service which gave an advantage of helping people no other hospital service can give. Also, would explain that it is never easy to work in community setting and there can be cases which are more challenging than others. Although I would tell them (believed in whatever I was saying) and kept them on their job doing what they were doing sincerely, internally I felt a dread as I did not know how to proceed further.
At the same time, G had again started approaching people, and begging to run her household. Mostly whoever she met, she would use bad language either for me or the HOD and this information invariably would reach me and I would feel a little low knowing fully well what I was trying to do for her and for her sister. In the mean time again, through multiple sources, it got confirmed that her father had left a will and some money in the Post Office and State Bank of India.
Almost daily I was getting some information or other about them mainly through HBT Services. Although I was trying, I was again feeling clueless how to proceed in the case. The pressing need was that S was improving in the ward and was to be discharged after a few weeks. Also, I was worried as it was amply clear to me with what all information I had that G was not complying with medicines and thus was heading towards relapse soon. Although we were able to provide treatment to both the sisters for their acute symptoms, we seemed to have no idea how they will be able to maintain themselves in the home setting.
Hence, one day, I rushed to the HOD and expressed my helplessness. During the discussions, we realized that we required a caretaker for them, at least initially for few months after discharge from hospital till they could take care of themselves. Again the MHA, 1987! Decided to take refuge under Section 52 - “the application for appointing guardian and manager to look after the person and property of a patient can be moved by a relative, public curator under the Indian Succession Act, the advocate general of the state or the district collector where property is located. The court will direct the person having the custody of the mentally ill person to produce the person for examination by the district court. District court can appoint the Guardian under Section 55 of MHA, 1987 where the mentally ill person is incapable of taking care of himself.”
Although the act had the provision of appointing guardian and manager for the patients, in this case who will move an application for the patient was not at all clear in the act. The HOD told me to approach the SLSA for appointing guardian and manager for the patient and that he wanted to see both the sisters living independently in their own house like any other normal citizen. On hearing this, I looked at him in quiet disbelief, admired his confidence but internally felt this as impossible in the absence of any responsible person who can take care of both of them.
Nevertheless, I wrote an application to SLSA for arranging a lawyer for the patient (G) stating all the facts of the case. Also to hasten this whole process, I myself went to meet the head of SLSA who took active interest in the case. However since he hardly had any idea about MHA, 1987, he requested me to give him some time to read the same. Within 2 days, a lawyer was appointed to present the patient in the court. He also suggested me that in the absence of any family member/relative, it will be better if I attend court proceedings to state facts about their condition. I wondered at that time that if a lawyer appointed to present their case then for what purpose I have to go to court. However, on the day of hearing, I coordinated with the lawyer and attended court. During this time patient kept on deteriorating as she did not take medicines, did not come for follow-up in OPD and did not cooperate with HBT Services while her sister was improving in ward and had started attending DART Services where she was found to be very good in her functional capacities, and hence had been placed in vocational section. In the first hearing in the court, the lawyer representing the case did not say anything, the judge himself read the case file, and the case was postponed for second hearing. I requested the lawyer representing the case to take active interest in the case as we had to discharge the patient but was of no use. The lawyer would ask me 5 min before every hearing to tell him about Section 52 of MHA, 1987.
In between, one fine Friday at 9.05 am (just as my working day starts) I received a call from the HOD wherein he very was upset with me that I could not ensure compliance for G. Although the call was of 2 min only, it disturbed me a great deal as I was trying my level best (attending all court hearings, had kept HBT team working on the case proactively despite all kind of constraints, had kept HOD abreast of all difficulties, etc) to do what all could have been possible. I felt a sense of outrage that despite knowing well about the intricacies of the case how can he say like this to me. Easier said than done…! Deep down also I had this sense of failure that HBT Services in this case had proven to be a complete failure as we could not ensure compliance and not prevent relapse and hospitalization. In addition, to know more about my HOD (as I was very new to the dept), I tried to ask other colleagues whether he (HOD) thinks rationally and realistically. I was told that to begin with you may not believe him, but gradually you would realize that it was a well-planned task which was achievable.
That particular day I did nothing for the case and kept on assessing what is going wrong and what can prove to be a breakthrough in this case. I ultimately realized that the entire failure of all my efforts was because no person was there at home to take care of them. I thus decided to meet head of SLSA again, and told him that what all happened in the court and to seek his opinion. I also explained to him that department will not be able to prevent relapses until we have a guardian and manager for them. He suggested to me to write an application to SLSA requesting for a change of lawyer, which I immediately did. I also requested him this time to look into the matter personally and appoint a lawyer who is a little sensitive in such matters and also that before going for next hearing we three should have a meeting to discuss the case and MHA (Section 52 in particular). Because of active interest of the head-SLSA, we three met in his office before the 4th hearing for around 45 min to discuss the provisions of MHA, 1987. In between more information regarding the patient kept pouring in and we were able to trace the will and details of the accounts father had left for the two sisters in post office and SBI. It was clear from the will that their father had clearly mentioned that none of his property (two houses) or bank balance (6 lakh rupees) goes to his son. However, they were unable to withdraw money from the same owing to their mental illness.
Meanwhile, S had improved and she was discharged with a contract that she will be regular with her follow-ups and will comply with the instructions of the HBT on daily basis. Through an nongovernmental organization (NGO) (Parivartan), I could easily arrange for the expenses of daily living for the patient; moreover, with her improvement and work in DART Services, I was confident that she would be able to do some work for living.
At the fourth hearing of the case, I again as usual waited in the courtroom. While waiting was reminded of a famous dialogue “tareek pe tareek pe tareek” of a Bollywood movie that truly describe the legal system in India. However, this time, the lawyer presented the entire case in detail to the judge. I felt confident because of the way she stated the facts about the case. However, the judge, after listening to the case, immediately asked that if we are saying that patient was fit for discharge then why an application for guardianship or manager for her. If she is fit, she obviously can take care of herself. Without thinking much, I started explaining to the judge about schizophrenia and soon realized that I am saying a lot but he was not able to understand. I ultimately told him - ”that in mental illness there are no absolutes. I am not saying that she is or will be 100% fit, she has some symptoms but is not that sick that she will need admission in ward. In most aspects, she will be able to take care of herself and if she has some support and supervision she will be able to lead a normal life. Especially I told that she does not know judicious use of money and is in a habit of spending too much.” All this made no sense to the judge and he appreciated the efforts and time that I had taken out for her. However, in his next sentence, he gave me the option of sending G to “Nari Niketan” or “Pingalwara” (an orphanage). I got a little agitated internally by hearing those words and again tried to explain to the judge that like other physically challenged persons who are blind, deaf, etc., who can live in society without creating any trouble, it is possible for this person to live as a responsible citizen in community without creating any trouble. As serendipity would have it, to my advantage that day, a few media persons and a senior judge of district court came to that room. After brief discussion between the two of them, one of the judges asked for proof regarding G suffering with mental illness which I promised to provide. The entire process was again postponed. I asked myself, “how can judges be so emotionless?”
That day even after returning home I remained disturbed. I was unaware that somehow I was getting too much involved in the case. Besides doing my responsibilities as a psychiatric social worker, I was getting emotionally involved. Every night before the hearing of the case I would pray to the almighty that patient G gets someone under whose guidance and supervision she lives respectably in the society. I kept on contemplating that her father probably knew what fate his daughters were doomed for and so probably tried to secure their future by leaving whatever he had in their names. He could also foresee that he will need people who will help them when he is no more and probably that was the reason why on every Sunday he himself would hold a meeting of around 30 people from different walks of life. Before the involvement of Department of Psychiatry, many people (close/distant relatives and friends) had, in their own way, tried to help (by giving money, household articles, clothes, etc.) the two sisters. However, help could not be sustained as the two would not put them to use properly owing to their psychotic symptoms. My thought process continued and the resolve within me also kept on rising that I would ensure that they can utilize whatever their father has left for them and to make them live as respectable and responsible citizens. It was probably counter transference that was operating… but I shall not dwell upon it! Following this, never again I approached my HOD, or disagreed with him, trying to tell or feel that nothing more can be done in this case.
In the next hearing in the court, I came to know that the judge who was hearing this case had gone on a long vacation and this case will now be heard in another judge's courtroom. My heart sank a little as I felt that the entire story now will need to be repeated. Luckily this judge happened to be the same who had come to our last hearing along with media personnel. He easily could recall the case and after reading the letter head of the HOD where all the clinical and psychosocial issues of the case were mentioned, immediately asked me to call any person with identity proof to give consent to be appointed as guardian. Regarding appointing manager, the judge refused and told that the NGO who has been taking care of them can continue doing the same. Although I tried to impress upon him the need for appointing manager, he seemed too adamant for the same. Hence, I reconciled as till now even this seemed like a distant dream. I immediately started looking for persons who could be chosen the guardian of the patient. I contacted persons from three different NGOs whom I knew were doing good work in the field; however, all refused to be appointed as patient's guardian. Some refused bluntly saying that they knew this case well and that she is a gone case and will never improve. Then I contacted our medical social workers who were working in the department to give consent for the same. No one was ready. Few were asking how much money they will be paid for the work. Then, I called my HOD to update him of the current situation and requested him to suggest some names. He suggested a few names (some I had already contacted and knew the answer, others I called). Finally, one psychiatrist (whose name was suggested by HOD) agreed though reluctantly. I went to the courtroom again where the judge added a new clause that guardian should not be a government official. His opinion was that a government official will have his own limitations due to being bound by his duties and so will not be able to fulfill the role fully as a guardian. I could not say a thing as I agreed and understood what he was saying.
By this time, seeing the perplexed look on my face, he probably understood that I was having difficulty finding a person and told me that he will be in the courtroom till 5.00 pm and I could come with the name of the guardian any time till then. I felt indebted by his gesture, as this gave me more time to hunt for the guardian. I contacted at least 15 different people but to no avail. Ultimately, I called the vice president of NGO Parivartan and told her the entire situation. She too initially refused, but agreed reluctantly after I promised that I will continue to manage the patient and support her in all possible ways. She gave her consent and submitted her papers in the court at 4.30 pm.
| The Travails and Joys of Managing Both the Sisters in the Community!|| |
Since both the sisters were now living at home, I started working on the recovery paradigm constituting of empowerment and reclaiming control over one's life; rebuilding positive personal and social identities; connectedness (including both personal and family relationships) and wider aspects of social inclusion; hope and optimism about the future; and finding meaning and purpose in life.
Although both the sisters had started staying together again in their own house under constant supervision provided by the guardian and HBT team, when I would visit them, the two were seen fighting with each other and complained to me like little children would do in front of their mother. The argument would be mostly on trivial issues and looked as if two Class 5 children were fighting with each other. I would try to handle their issues and pacify both; they would complain to me following which they would calm down. On retrospect, I realize now that at that time I was almost playing a role of a mother.
I recalled that relationships are vital to recovery, they shape identity, and healthy personal relationships contribute to well-being and can be a critical factor in achieving recovery. Using this conceptual framework and evidence base, I started working on rebuilding their relationship. Separately while talking to each one of them, I would say how the other one is concerned about her. On hearing that they care for each other, they would usually have tears in their eyes and gradually stopped verbally abusing or blaming each other. Although initially they cooked separately and moved in different directions for almost each and every decision, gradually they started emotionally relating and caring for each other.
In between, G stopped taking medicine and refused to come for follow-up. It was discovered that she was being paid directly by the guardian. To make her compliant, it was decided that both sisters would be provided grocery items instead of money through the HBT team, and this was made contingent to her follow-up visit and taking depot preparation. This improved her compliance to medication. I however did not like at all and felt as if I was doing “human rights violation” in the name of ensuring compliance for them. I again went to the HOD telling him how I was feeling. He pacified me by saying that anything done for the benefit of the patient can never be wrong or termed as human rights violation. He further motivated me saying that this was probably the first case where an unknown mentally ill patient had got guardianship from court in such a short time and that these two sisters have all the resources that are required for community living, and I should continue with what I was doing to make it possible for them.
Almost every alternate day I would get a call from some lawyer, judge, principal of a famous school, social worker, etc., telling me that the two sisters approached them asking for money. Due to this, mostly I would feel that the role of the guardian was being carried out by me rather than the person who was appointed as guardian.
Hence, many times, I would feel burdened and irritated by the multiple demands the two sisters would have. I practically was running their household. I would wonder about the role and responsibilities of a psychiatric social worker? Was I trained professionally to carry out these duties? Or is this what is meant by psychosocial care? I very well knew the answer to these questions, but was sure that without handling these practical issues in this case, any treatment for both sisters would fail; so much so that even with having a house of their own, they would end up in some orphanage or a government-run social welfare organization.
The next step in moving ahead in the case was to ensure that they started cooking for themselves (till now would only make breakfast and tea) and to have income for themselves. Meanwhile, the two had gained confidence in me that I am concerned with their welfare and had started sharing (facts and also the emotions involved) with me. However, when it came to money many times they tried to manipulate me. They told that G had sold their house in Solan to someone and also that they received call from some numbers who would ask for money from them. Through SLSA I came to know that someone had cheated them of approximately Rs. 3 lakhs. I immediately requested SLSA to arrange a lawyer and file a case in district court for appointing a manager for them. The judge appreciated the kind of improvement that they had achieved, despite little support. I was at different times receiving accolade of appreciation from different quarters. Unfortunately, though the legal fraternity was eager to appoint a manager for them, the guardian refused to take up this responsibility. It came onto me… again! As usual, I rushed to HOD (treating psychiatrist) for a solution who realizing the gravity of situation immediately called a meeting of probable candidates who were also members of Parivartan. However, I was shocked that not only all refused but instead suggested that since I knew about the case, I am the best person to be appointed as manager for them. I did not/could not say a word except for nodding to the suggestion as it was clear that no one was ready to take up that role. At the same time, I was confused and it was unclear to me if I was moved by my professional duties or personal involvement. However, I knew internally that I was too involved to leave the case. In my attempts to rehabilitate and empower them, I had lost myself as a professional social worker and was acting more like a mother for them, and I finally gave my consent. The judge appointed me as their guardian and manager. The next day I got their account ceased so that no one without my consent and signature could withdraw or transfer money from their account. I also filed a case in crime branch against the person who had cheated them. Compliance to treatment was ensured through regular visits by HBT team.
Social workers can play a key role in enabling people to develop their strengths and abilities, and in facilitating opportunities for mutual support. I realized that the elder sister (G) was good in household work (cooking, cleaning, etc) whereas the younger one (S) who got training in DART Services was better and comfortable working outside home. Hence, I started thinking that if they further developed these abilities, it will be possible for them to run the household like a (married) couple would do and started encouraging them in the same. I also realized that by facilitating this I would be helping them have control on their own lives, which was the first paradigm of recovery process. To a great extent, I succeeded in doing so as without any external help the elder one was now cooking at home and younger one was receiving job training at a nearby facility from her home. This also helped me achieve the second paradigm of recovery approach as this lead onto them to rebuild positive personal and social identities.
| The Current Scenario|| |
It is over 2 years since G came into contact with the departmental services, followed by S within a space of few months. For the last 1 year, everything has been going on well, and both have been able to achieve and gradually enhance their skills centered around activities of daily living, and to coexist congenially. Their social acceptability has increased and they are no longer seen as a nuisance by others. The frequency of HBT visits has also gone down considerably. Last but not the least, my role as a parent has reduced considerably.
| My Reflections|| |
Professionally, this case seems like a live movie, which has taken me through different stages of helplessness, frustration, anger, guilt, fear, grandiosity, and altruism. Since I could overcome all the obstacles, it has given me personal and professional confidence to solve a real life problem. During the past 2 years period (still continuing and counting), I became confident in handling rehabilitation of patients using techniques and skills that I learned during my training as a psychiatric social worker. Initially, I worked as a full-fledged psychiatric social worker taking active guidance and suggestions from the HOD (treating psychiatrist), who showed full faith in my abilities as a psychiatric social worker. His words would often echo in my mind that - in chronic mental illness, the psychiatrist has a limited role and psychiatric social workers can play a vital role in the management, rehabilitation and after care of patients. Gradually, he handed over the case entirely to me for management purposes. This step on his part raised my confidence a great deal and I emerged as a junior faculty making and revising the management plan for the patient myself (while keeping the treating psychiatrist informed about the same). Gradually within this period, I independently started guiding students in rehabilitation of unknown mentally ill patients. As the case progressed my professional needs kept on getting satiated and I transited from a medical social worker to a psychiatric social worker to a junior Faculty of PSW, who later started functioning as an independent (i.e., having confidence in one's abilities, understanding, and application of professional skills) faculty in the field of PSW. This process of professional self-actualization can be best conceptually understood for me using the framework of Maslow's triangle of personal self-actualization  [Figure 1]. My HOD once said, “I am proud of your role and growth, not only as a person, but also as a professional.” This is probably the biggest compliment that I could have ever got!
In fact, this case taught me what chronic mental illness means and what kind of social issues are associated with mental illnesses. I used to think that a mentally ill person cannot be believed but here was a person (G) who despite gross deterioration had intact cognitive functions. Probably, this might have been the reason that UNCRPD redefined disability and the legal capacity of person with mental illness. It has given me new insights into the community rehabilitation of unknown mentally ill persons. Simultaneously, it has made me wonder why community living has not been promoted within the proposed mental health facilities, and why other departments are not working on such a viable model in our country. I hope that I shall be able to translate the experiences and learning from this case of “mentally ill sisters” into a symbol of hope and development of proper rehabilitation services in the community for the “unknown mentally ill.”
First and the foremost, I would like to acknowledge my gratitude toward my HOD for providing active guidance, encouragement, support in handling the cases and also for bringing me back to my profession. I would also like to thank the legal fraternity who came forward to support the cause of mentally ill persons without any social support and helped me a great deal in overcoming obstacles from time to time. Finally, I thank the two special people (patients) of this exposition, without whom I would not have been able to rediscover myself.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
PD. Social Work – Philosophy and Methods. New Delhi: Inter-India Publications; 1994.
Mental Health Act 1987; with Short Notes and with Central MHA Rules 1990. New Delhi: Delhi Law House; 2003.
Tew J, Ramon S, Slade M, Bird V, Melton J, Le Boutillier C. Social factors and recovery from mental health difficulties: A review of the evidence. Br J Soc Work 2011;35:1-18.
Maslow AH. Motivation and Personality. 2nd
ed. New York: Harper and Row; 1970.