SCARF first became aware of Senthil when the Communitly Level Workers from local NGO’s trained by SCARF brought him to the attention of the clinical team of SCARF conducting psychiatric clinics in his village.

The CLWs informed   the team of the presence of a young man who was kept chained up at home. They had tried to intercede and convince the family to bring him to the psychiatric camps being conducted regularly at their village but could not succeed as the very idea of releasing him from chains created fear among his family as well as in his neighborhood.

Members of the SCARF team then visited him at his house and found him sleeping on a straw mat chained to the window of his room. The family informed the team that he was served food at the same place and had to answer nature’s calls there. He had not had a bath for a long time.

An interview with the family established that Senthil was 24 years old that he was educated up to 10th standard and that he had suffered a psychotic breakdown at the age of 15  (which had lead to the discontinuation of his studies). Following the onset of illness he was taken for treatment to the Govt. Hospital where he was on irregular treatment for about three years. Irregular treatment was attributed to the difficulty in traveling to the hospital and the associated expense of travel.

Following the discontinuation of treatment his symptoms had worsened and he became violent. The family then had no option but to put him in chains. He has remained that way for the past five to six years.

With the family’s consent SCARF began treating him and over a period of eight months was able to demonstrate significant improvement in his condition that the family and neighbors consented to the removal of his chains. Senthil is now free of his chains and on regular treatment his “cure” has encouraged other villages to also seek treatment.

THE TWO SISTERS

Families in India are the primary care givers of clients with chronic mental illness. Caregivers take care of every aspect of the patient from medication compliance to the activities of daily living. The reasons for this lie in the social and cultural traditions, as well as the mental health infrastructure in the country.  With the paucity of trained professionals in the area of psychosocial rehabilitation the work and the dedication of families are the key to successful rehabilitation out come. They should be appreciated. Very often the families undergo a great deal of stress, heavy responsibilities and financial constraints.

Psychosocial rehabilitation is a process that facilitates individuals who are disabled by a mental disorder to reach their optimal level of independent functioning in the community. A whole spectrum of intervention is covered from psycho education to skill training or work rehabilitation and case management. As families have traditionally been involved in all aspects of care in India, their absence is usually very sharply felt. The larger community had to take the place of the traditional family in this particular case.

The importance of families in the care of people with serious mental illness is very often recognized only when they are no longer around!  This poignant tale of two sisters demonstrates the intensive case work and efforts put in by the social workers and the community to help the patients remain in the community.  The real challenge has been working on the process of rehabilitation of the two girls, VNA and SNA,  after their parents passed away.

VNA and SNA  were brought to the out patient department at SCARF by their paternal uncle, NRJ in June 2005.  NRJ had been contacted by the police as he was their legal guardian. A complaint had been lodged at the police station by VNA that  SNA had thrown her out of their in the middle of the night  after a quarrel. SNA was reportedly  refusing to open the door. After several failed attempts to get her to open the door, the police had to finally break in. The secretary of the housing colony  very kindly arranged for security for the night . The next morning, the uncle approached SCARF with both the sisters, for help.

Since the family had remained out of contact even with the closest of relatives, no clear history was available about both the sisters.

SNA, The Younger Sister

SNA was a 30 year old lady, belonging to a conservative Jain family. At the time, she was brought to SCARF, she was living with her sister, VNA, in the quarters of a government owned orhanization. Both her parents were dead, the mother about a year ago. The family had no contacts with any close family or with neighbours.

When brought to SCARF,  SNA was extremely disturbed, aggressive, abusive and  irritable. It was apparent that she took very poor care of herself. She was extremely uncooperative for any interview and  had to be admitted at SCARF’s residential facility at Thiruverkadu. She was highly suspicious of everyone around, especially her sister VNA, which was why she had thrown her out of the house.  She was secluded and  given parenteral medication.  After 2 weeks of intensive treatment,  she began to show improvement . The symptoms gradually remitted over a period of one month. As she became better, she provided some history about their problems.

Both the sisters lived in complete isolation form the outside world. SNA would go out infrequently to buy their meals. The doors and windows of the house would be shut all the time. The telephone line had been disconnected because of non-payment of bills, cutting off the only possible reach to the sisters.

SNA reported that she would hear voices  talking to her all the time.

As VNA was very agitated that her sister was secluded, we had to transfer her to the city centre. The psychologist and the social worker worked intensively with both the sisters. SNA was willing to take her medicines and come for review regularly. VNA was adamant and said that nothing was wrong with her and that taking medicines was a personal decision.

VNA, The Elder Sister

This  36 years old lady, from a conservative Jain  family, was employed as an attendant at  the Airport Authority of India.  She had acquired the job on compassionate grounds as her father, an employee, had died while in service. She had been working for about 10 years. The family lived a secluded life and never participated in any  social gatherings.

Details about the onset of illness are not known. According to information obtained from her parents-in-law, VNA was noticed to be “abnormal” from  the very beginning of her marriage in early 2003. She was irritable and angry all the time. She lacked concern for  personal hygiene. She insisted on going back to her parental home and refused to accompany her husband to Dubai, where he was employed.  The marriage was not consummated. They had tried all means to coax her to either go to her husband or to  stay at their home in Chennai. During the year after the marriage,  VNA steadily grew more and more distant, refused to talk to anyone, her personal hygiene worsened and she was noticed to be sleeping poorly. The parents-in-law, sent her to her parental home to live with her sister and mother, in late 2003. They also actively considered going to court for a legal separation.

For almost a year, VNA remained at home, did not go to work, and completely isolated herself from family and neighbours. Repeated notifications from her office too went unheeded.  The problem worsened when their mother passed away a year ago. VNA could not come to terms with her mother’s demise. She refused to open the door for the neighbors or anyone else. As there was no bonding between the sisters, each kept to herself in their own rooms and interacted very little.

VNA has been admitted to residential care 4 to 5 times as her medication compliance was very poor. She had not gone to work for a year and remained isolated at home along with her sister.

SNA is the younger of the 2 sisters.  She is educated up to the 10’th Std. According to the uncle, SNA was more stable and fell sick 5 years ago. She has been admitted to residential care once. Her uncle saw her a few months ago and she seemed well. She used to cook, clean and take care of the home. She used to take up small jobs and supplement the family income.

A mental state examination on the day of admission for VNA revealed a thinly-built individual, rapport was poor and she kept saying that she wanted to go home. She had hallucinatory behavior and looked depressed. She lacked insight and kept saying that medication gave her side effects. Physical examination and preliminary investigations were within normal limits. She was started on medication and as she did not show improvement she was given 5 ECTs. She recovered sufficiently although insight was lacking. She was stabilized on long acting depot preparations once a month accompanied by oral medication.

SNA was extremely disturbed, aggressive, abusive, irritable and apparently took poor care of herself. . She had to be secluded and sedated. After 2 weeks of treatment she showed improvement and at the end of the month she reached partial clinical remission.

As there were no family members, interventions had to be targeted at the community, like the office staff, neighbors and family friends. The guardian was an elderly man who was aware of the illness but he had his own health and family problems including a son who was mentally ill. And  as he lived far away from the quarters he could not help the girls. Both sisters were quite suspicious of him. We requested him to help in getting the house repairs done ( as the door was broken down) buying groceries and in cleaning up the place as it was very shabby . The social worker visited the office and spoke to the  office staff and the secretary of the Quarters to explain to them about the illness and the need to be supportive .The office staff were aware of the illness as the client had shown abnormal behavior in the office prior to her long leave ..The office supervisor was aware of the family background and was extremely supportive of VNA. She saw to it that her  long leave was regularized and her medical bills could be claimed. She also encouraged her to take her medication and would find out from the neighbor the reason for her absence from work if she did not attend the office.

The Story of TV

It is often said that rehabilitation programs should be with clients and not for clients. This group home is a typical example where a program has been initiated due to a need felt by the client and family. There is a  need for group homes where the number of residents is small and easily manageable  and the most important criteria is that clients are from similar background. They have their independence and they also help each other like family. They have their differences but they always sort it out with the help of a social worker. Family groups should help in setting up more of these homes as there is a growing demand for such facilities especially for women who cannot live alone, adjust with their siblings but are otherwise well enough to reside in a highly supervised residential facility. As their house keeping skills are intact they are able to manage the home well. The successful running of the home is possible only with the help of clients, the trust and support of care givers and the cooperation of the community who were extremely supportive.

The extreme vulnerability of women patients is brought to the fore in this case history. A lot has been written about Indian families and their support for clients with mental disability. This particular history demonstrates how clients are neglected in spite of efforts put in by professionals. This is the history as given by the client.

TV is a middle aged woman who befriended our social worker when she went to Bavishya Bhavan, Scarf’s residential rehabilitation centre for women located at Tiruverkadu, about 14 kms from the city of Chennai. TV told the social worker that she wanted to help out in the centre as a volunteer .The social worker asked her to report to the Anna Nagar day care centre as it was closer to her house.

TV used to visit the day care center twice a week and she used to bring cakes for all the clients and spend large sums of money on food and give donations to SCARF and other organizations .We never thought that anything was wrong until the supervisor of the Vocational Training Centre observed that she was muttering to herself and a week later visited the supervisor’s house in the middle of the night. She then realized that TV  was unwell. According to the client she is the second of 6 children .She has 3 brothers one elder and 2 younger than her. She also has 2 younger sisters. All of them are married and well settled in Chennai. Both her sisters are working for the government and are well placed in life. Her elder brother lives in Katpadi and is under treatment for mental illness.
TV was educated up to the 10th class and was married at the age of 20. She never had any children .Her husband worked for the Government Transport Department and suddenly passed away at the age of 49 due to a massive heart attack in the year 1992.At the time of her husband’s death she was aged 39years. According to TV her husband’s death came as a big shock to her as he was apparently in good health and never suffered from any ailments as such.

TV was very upset as she had lived a very sheltered life. Her brother was very supportive and initially bought her a flat with the settlement money. It is here that the illness started. TV felt that the neighbors were talking about her .She felt that they called her a woman of ill repute. Against her brother’s wishes, she sold the flat 2 years after it was bought for a price lower than the market rate. Her brother was very angry and washed his hands off her .He did not realize it was an illness. TV was taken for treatment by her 2 sisters in 1995 to a private psychiatrist for sleep disturbances, persecutory delusions, confusion and hearing of voices. She discontinued medication and changed houses 5 times. Every time she rented a new house, she lost the advance amount she had paid the previous landlord as she did not give proper notice, changing her residence on an impulse based on her paranoid delusions. Her medication compliance was very poor and her sisters could not take her to their homes as they lived in a joint family.

TV first came to SCARF in 1996. She had already sold the house and given a lakh of rupees to a political party member to start a social service organization  She gave the money without a receipt or any witnesses and lost it all. She also lent money to her own brothers and sisters who did not return it. The social worker contacted both her sisters and brothers and they refused to have anything to do with her. The sisters said it was the duty of the brother to take care of her and the brothers refused to even  talk to the social worker. Medication was started on an out patient basis. As she was poorly compliant with medication, she was admitted into the residential rehabilitation centre for 2 months. She did extremely well in the structured setting  and since she felt better, she was discharged. The staff helped her find a house and she started attending the day care regularly. She used to help out in the canteen. She was extremely suspicious and did not have a rapport with the staff.

Her money management skills were very poor and by the 20th of each month she was borrowing money. She received Rs 1317 as pension and Rs 800 as interest. She also had a few fixed deposits for Rs 50000 and some gold. All these assets were slowly sold and the fixed deposits were withdrawn because she would buy things on an impulse like clothes and gold ornaments and also sell it away whenever she needed money. In order to improve her compliance medication was given at 4.30 just before she went home. She did not want to take it as it made her drowsy and she woke up very early. Depot medication was tried  but it did not suit her as it made her drowsy for the first 5 days.. Her compliance could not be ensured. The social worker tried to help her get a job to supplement the income but she would work for a few days and then give it up .She was employed as a cook, a helper, and even in SCARF as an assistant cook. She would work for a month and give up the job very easily.

She continued to change houses and as all the gold and money was lost, she sold her gas connection, cupboards, cots and other articles. She was readmitted to the residential rehabilitation centre at her own request as she felt her landlord was troubling her .She was in the residential centre only for a month when she wanted to be discharged. She has again taken a house on rent and the social worker put her in touch with a group of care givers in Chennai who run a group home. She is working as a helper in the home for 6 months now .She goes to work about 20 days a month, and takes leave very often. She is given her meals and paid every month. Her compliance and money management skills continue to be very poor and she has just a few possessions left. Her employers are extremely tolerant and do not mind if she absents herself. She on the other hand continues to work as she gets her food and she also needs the money to pay the house rent which is Rs 2000 a month. The only support she has is SCARF and the group home where she works. One of her sisters has moved residence without informing her. She continues with her lonely existence in spite of having a family.

ANGUISH RESOLVED….. NOW I AM CONTENTED

It was another bright sunny morning. Sunil’s father was in the verandah enjoying his coffee and glancing through the morning papers. The house was silent but for the chirping of the birds in the garden and the rustling of his newspaper. As he was turning the pages, a news item caught his attention. A small bank was in the process of being taken over by a large multinational bank. Depositors were asked to withdraw their money from the bank before the last working day of the next month. This was still about a month and half away, but Sunil’s father was anxious. A large amount of Sunil’s savings were in that bank.

He looked inside the house. Sunil’s room was still closed. His mother was busying herself in the kitchen. He decided to discuss it with her before talking to Sunil. He went to the kitchen and cleared his throat. His wife looked up quizzically.
“ Sunil has to go to the bank and take out his money. The bank is merging with another bank. So they want the depositors to close their accounts and take their money before the end of next month.”
“There is lot of time. No hurry” came the quick reply.
“ But we have to convince him to go to the bank. He may refuse to do it”
“ You are always trying to say something adverse about him. He is perfectly all right. You are just irritating him and finding fault with him” was her angry retort.

Sunil’s father realized it was no use talking to her about her son. He had touched a sensitive nerve. As he walked out of the kitchen he could still hear her muttering something under her breath. He glanced at the clock. It was a quarter past 7. He decided to go about his daily chores as he was sure his son would not come out of his room before 9 o clock.

It was close to ten, when at last Sunil came out his room. His father called out to him and said, “ Sunil, your bank says it is giving all depositors time till the end of next month to take out their money. You should go to the bank once.” He quickly added, “ I will accompany you if you want.” Sunil nodded, grunted something and moved away. His father stared behind him. He had expected something like this as a response but he felt hurt and helpless as always.  Why did things go wrong?

He suddenly felt drained of energy and sank in a chair. Why? Why did it happen to me? How long should I suffer like this? Where did I go wrong?

He closed his eyes and images started appearing in his mind. Sunil, as a day old baby, smiling in his sleep. Sunil as an infant taking his first steps, saying his first words, his first day in school. Sunil the responsible elder brother to his brothers and sister, his anxiety during exams, his concern and keenness to help solve problems at home, his first day in college, his first job, his first trip abroad, his support during his sister’s wedding, his responsibility towards the family, a happy but shy Sunil getting married,  Sunil becoming a father- images kept flashing by.  Along with came unpleasant images too.

Sunil a very soft spoken quiet introverted boy never impolite, now shouting and arguing loudly with his wife and father, getting irritated for small things ;  Sunil who was very clean, punctual, and very methodical at home and work becoming careless about appearance, missing work avoiding his household responsibilities; Sunil, the once responsible and affectionate elder brother now having severed his relationship with his brothers and sister, his failed marriage leading to divorce .

Tears started flowing from his eyes as he recalled the past 15 years of the life (or is it mere existence) of his family. As soon as Sunil earned his B.Com degree, he joined his cousin’s company and worked in the accounts department. He was a good worker and responsible too. Things were smooth sailing till his cousin fell sick and he had to close down his company. Sunil took it in his stride and within a few months got a job in Oman. It was he who consoled his parents when they were not too happy about staying away from him. He was in regular correspondence with his family and also supporting them financially. He took up a better job there and was quite successful in his new job too. That was when his parents decided to get him married. After all the preliminary formalities, he flew down to India  for his wedding and Seetha became his wife.

He and his family were quite happy during the initial period of his marriage. He went back to Oman at the end of his vacation. When his father voiced his opinion that he should take his wife with him to Oman, Sunil agreed and tried getting a family visa for her.  After a year, when it became clear that it was very difficult to obtain the family visa, he decided to return to India for good.

Soon after his return, he found employment in the TVS group and settled quickly. He appeared quite content with his life. But within a few weeks things started changing. He gave up his job saying the salary was inadequate. He found employment in a few other offices but could not continue for more than 2-3 weeks in any place. Gradually, the situation at home also started changing. There were frequent quarrels between the husband and wife. Thinking back now Sunil’s father felt he could not blame his daughter in law completely. She felt betrayed because her husband was not earning enough and did not stick on to a  job for more than a few weeks.  She became pregnant in the meantime and what should have been a joyous occasion became very stressful for all of them.  By the time she delivered a female baby, he had become completely withdrawn, asocial, lacking in personal hygiene and showing excessive irritability. He was found confined to his room, which was as shabby as his person, and was found talking and laughing to himself.  He was not the Sunil they knew anymore.

Sunil’s father reflected to himself  “ Did any of us handle him properly then?” The honest answer was NO. All of them tried to ignore him and avoided him like an untouchable.  He was perceived as a constant source of embarrassment, especially when he used to eat like a glutton unashamedly and finish off everyone’s food on the dining table. All of them accused him of bad behaviour and shunned him. Their attitude only worsened his behaviour and he became difficult to manage.

He recalled now how all of them including him reacted when his friend suggested that Sunil be taken to a psychiatrist. It was thanks to his friend’s perseverance that Sunil was taken to a psychiatrist and started on medical treatment.  While Sunil’s mother was not very happy about a psychiatrist treating her son, she could not help accepting that he was showing improvement with treatment.  It was such a refreshing period to see Sunil normal again. He started taking care of himself and showed interest in day to day activities of the house. The happiness did not last long as his wife refused to come and live with him. But he accepted this and continued to live with his parents.

The stigma of mental illness and inability to accept reality persisted in his mother’s mind. So when she felt he was improving, she gradually started reducing the dosage and stopped medicines on her own. His father reflected sadly now that he should have been more involved with the treatment to ensure that it was not discontinued.  He had remained passive in order to avoid confrontation with his wife. How detrimental that has been to his son’s life! His wife stopped the psychiatric medicines on the pretext that they were eating into their monthly expenses especially when they had to buy medicines for Sunil’s diabetes too. In the bargain, Sunil suffered a relapse of psychosis, which needed intensive therapy again. This went on for a few years and in the last few years he has gone back to square one, remaining confined to his room.  His mother vehemently opposed any psychiatric intervention even now. Any hopes the family had about Sunil’s reunion with his wife ended with a divorce suit filed by her. Once the divorce was through they lost all contact with her and the child.

Sunil’s father realized he had been crying all this time, thinking about the past. He also thought he could have avoided lot of trouble had he acted differently and sensibly instead of being carried away by others’ opinions. He decided he would try now to set right the past.

After making discrete inquiry among family and friends he came to know about SCARF and visited the centre on his own seeking help for his son.  He found himself talking very easily about all the problems of the past 17 years to people who were understanding and sympathetic. He had never realized it could be easy. He found himself paying attention to what the doctor and the team of social workers, occupation therapists and case managers were saying. He realized his son was suffering from an illness called SCHIZOPHRENIA and was oddly relieved. After all, his son was not purposely behaving the way he did! He had an illness! And when he looked around he saw several others with similar problems who had improved with treatment. He felt hopeful for the first time. If only he could bring his son here!  He also remembered he had a wife to convince and deal with. He was suddenly not too hopeful again.

He was hesitant to meet the doctor now and was surprised when she did not mind the patient not being brought. After a detailed interview he was told his son suffered from paranoid schizophrenia which was still treatable. He was even more surprised when the doctor gave him a prescription for medication for his son. He was not sure if he could make his son and wife accept to take medicines. When he voiced his concern, he was advised not to rationalize with Sunil at the moment and only convince the mother. The medicines were to be given without his knowledge for the time being. What was even more surprising was the doctor’s offer to visit Sunil at their residence.

A doctor, social worker and occupational therapist visited their house individually and sometimes together frequently. Their initial task was to convince the mother who was very skeptical of any effort taken regarding Sunil. However she agreed to dispense the medicines to him either with or without his knowledge. Within 2-3 weeks of therapy, the father was able to see some changes in Sunil, for the better.

When it was almost a month after starting medication, Sunil’s father reopened the topic of going to the bank to take out his money. He could not believe it when Sunil agreed to do so and did it the very next day. He realized his prayers had been answered at last. His son was definitely improving steadily if slowly. Sunil became friendly with the home intervention team members and started looking forward to their visits eagerly. Gradually they were able to make him go out of the house everyday on errands and made him more active at home.

His communication improved and he was persuaded to attend the day care centre of SCARF for rehabilitation and vocational training. He started attending regularly and gradually his old ways of punctuality and discipline returned. Initially he showed little interest in any activity and had to be coaxed to do work. Gradually he started showing interest in typing and practised the same everyday. He also started doing data entry and regained his forgotten skills in handling computers. He was trained in improving his communication skills and he became quite friendly with people. He was reluctant to go out of SCARF for employment due to fear of rejection. But in course of time, the rehab team could motivate him to attend interviews for jobs in near by areas. Though unsuccessful in the first few attempts, he was able to impress interviewers to the point of getting short-listed. He managed to get a job as office assistant in a private concern close to his residence within a few months. When compared to his previous jobs, this was definitely not very lucrative, but it offered hope and helped him pick up the threads of what remained of his life. The job brought him from behind the closed doors of the gloom in his bedroom, to the world outside. It has helped him reintegrate himself into the society that had shut him out earlier.

He still suffers from his delusions and hallucinations now and then, but he has learned  to work around his problem and function effectively. He has understood that his illness needs medication for a few more years and is very compliant with treatment. Today his parents are able to visit their other children who live elsewhere in the country leaving Sunil alone at home. Sunil is able to cook for himself, look after the house, attend to his work, and take medicines regularly on his own. He also knows he can call on SCARF in case he needs help. He is still very reserved and does not open up easily but he is not incompatible with society. His father calls on the doctor at SCARF regularly to collect medicines on Sunil’s behalf when he is busy with his work. He is no longer the pathetic old man with a lost look on his face. The happiness and peace his son’s recovery has brought home is written large on his face. A year after coming to SCARF, he told the psychiatrist once, “ In the past 15 years there were several nights I cried and remained sleepless. I was scared and worried about our (wife and self) last days. Will my son ever realize and act if either of us have any problem needing help? The bigger worry was what will happen to him after us. Today I feel calm and confident that Sunil can not only take care of himself but also make our last days on earth comfortable. I will die in peace when my time comes, Thanks to SCARF!”

KANNIAPPAN

Kanniappan is a 42-year-old illiterate man from a village, lying some 15 kms from the Thiruporur centre. When first met by the Community Level Worker (CLW) he was found sleeping in the village garbage dump. He was dressed in dirty, torn clothes and had matted hair and scruffy beard. It later emerged that he had not changed his clothes or had a bath in the past few years. Upon enquiring it surfaced that he was married and that he had a son (who was mentally retarded). The CLW also came to learn that his wife was employed at the nearby mid-day meals centre for school children.

The CLW then met the wife who informed her that her husband had been a responsible and hardworking man who found regular work to support his family till his illness started 7 years ago. He has since remained unemployed, spent much of his time in the garbage dump, constantly carrying on a conversation with the voices that he heard and also on occasions turning violent and abusive and throwing stones and garbage at people. All in the village feared him and avoided him, including his wife.

He had never been taken for treatment, as they had no access to a mental health services and also due to he fact that she was not aware that treatment was available for mental illness. The CLW then informed her about the rural mental health clinic of SCARF and offered to treat her husband. But she was extremely hostile towards her husband and refused to bring him for treatment. The CLW over the next two months frequently met the wife and tried to convince her to start treatment for her husband but had little success. During once such visit the wife’s supervisor at the mid-day meals centre became aware of the situation and with his help the CLW was able to get her to agree to start treatment for her husband.

He was brought to the next psychiatric clinic conducted and was seen by the psychiatrist who diagnosed him as having schizophrenia and prescribed appropriate medication. Over the next five months Kanniappan was visited regularly by the CLW and given his medication. On regular treatment over the next 5 months he recovered well from his. He no longer heard voices or was seen talking or laughing to self, he was no longer violent or aloof, he had regular baths and meals and had also started living with his wife and son again. By the end of the 5th month he was able to take up a job and has since then been regular to work and is now employed in a transport service company.

He comes for regular follow-up and is on maintenance medication.

SUNDERAMURTHY

Sunderamurthy is a 28 years old illiterate, unmarried man living with his aged parents in a village, some 20kms from a rural mental health center of SCARF. He had been working as a goatherd prior to the onset of illness about 6 years ago. Since then he has been unproductive, constantly wandering around the village, talking and laughing to himself and hurling abuses at everyone he met. He was however not violent   and the family generally did not find him troublesome.

He was initially taken for religious treatment at a nearby temple where he was kept chained for 48 days but following no improvement in his condition he was brought home and has since remained untreated. The family when first approached refused treatment, as they did not believe that his illness could be treated with medicines and also due to the fact that he was not difficult to manage at home. But over the next few months when they saw the improvement in some of the other mentally ill persons who were receiving treatment from the SCARF centre they approached the CLW and indicated their willingness to get their son treated. He was seen by the psychiatrist and prescribed antipsychotic medication. He was regularly followed up by the CLW who visited him at home to monitor his condition and ensure compliance to medication.

After regular treatment of 3 months, Sundermurthy recovered sufficiently to go back to his profession. He no longer laughs or talks to self and is able manage his needs by himself. He is currently on regular follow-up and on a maintenance dosage of medication.

A recent photograph of Sunderamurthy with his goats

SAMBANDHAM

Sambandham was a 41 year old married man living with wife and two children in a village that has poor access to any service and has only two buses passing through it the whole day- once in the morning and once in the night.

Sambandham has been ill for the past four years and has remained untreated, as he had no access to a mental health facility. His wife who was a weaver like him had rarely stepped out of her village and had no knowledge about mental illness or where to get it treated.

Since the start of illness four years ago he gradually started isolating himself became withdrawn, stopped communicating with others and spent much of his time talking to himself. He stopped working on the loom and had not done any work for the past three years.

When the CLW approached the family and offered treatment they readily agreed. He was seen by the psychiatrist and prescribed appropriate medication.

Over the next three months he gradually improved and by the end of the third month was able to start weaving again. Another four months all his symptoms remitted and he was back to his old self. He is currently regular follow-up and maintenance medication.

Architect of her life

Mrs. S is a 37 old married woman from a middle class family in the city of Chennai. The first of five siblings, she took a diploma in architecture. All her siblings are married and settled. She is married to a person who was employed in a private firm in the city of Trichy, which is 300 km from Chennai.  The couple had a male child who is now 5 yrs old. She lived with her husband and in-laws in Trichy. The client was reported to have been ill treated by her in-laws and was sent home alone without any attributed reason after two years of marriage. Her husband and child were staying in Trichy. The client’s family was unable to give any reason as to why she was sent home. She was found to be functioning well and participating actively in the household routine. After few months she developed psychiatric symptoms.

She felt she was under the control of an evil force and acted in accordance with the commands of the ‘evil force’. She believed her in-laws had done black magic against her. She felt a sour taste in her mouth and spat on the floor several times during the day. She had to be forced to bathe and change her clothes. She remained idle at home and did no work. Her communication was poor and she remained emotionally detached from her family members. She was found to be talking about her husband and child often and wanted to go back to them. She showed no interest in taking any responsibilities at home. She was later taken to a psychiatrist, who diagnosed her as suffering from schizophrenia and initiated medical treatment. Despite being on regular medical treatment, she has been continuously ill for the past 5 years.

At the time of referral, she was not interested in attending the day care center at SCARF. The intake assessment results and the case manager’s report showed her as having all the symptoms stated above and needing intervention at home.

A home visit was conducted and intervention began. Based on the areas of dysfunction, a rehabilitation plan was charted out. The primary care giver was given the copy of the monitoring chart along with the rehab plan. Counseling sessions were held for the client and her family members. Regular follow-ups were done.

After home intervention, the client’s level of functioning has improved. Her communication and interpersonal relationship with her family members has also improved to a great extent. She now takes her household responsibilities more seriously and is functionally independent. With her parents’ support, she has now rejoined her husband and child and is managing the entire household independently. On the suggestion of her mental health professionals, her medication intake is strictly monitored.

Dedicated case management: A comprehensive strategy

Mr. Kumar is a 40 year old man employed  in  an auditor’s firm . His employment comes after more than two decades of suffering from the agonies of schizophrenia, multiple admissions to treatment facilities and years of fighting the forced compliance to a medication regimen.

Kumar was born the youngest of five siblings, with three older brothers and one sister. He grew up in a joint family and had, in his words,  “a very conservative upbringing” with respect to socialization, recreational activities etc. After an academically brilliant track record at school, he undertook a graduate degree course in Commerce. Simultaneously, he also started preparations for the membership examination to the Institute of Chartered Accountants of India.

In 1981  when he was 19, Kumar  failed in his intermediate Chartered Accountancy examinations and was very upset about it. His family too was upset as this was his first ever failure in any examination. Gradually the family noticed that Kumar became very irritable for small reasons. He made no attempt to  go out of the home and kept complaining that his failure was a plot by the Institute of Chartered Accountants. Assuming that things would normalise  in time,  the family remained patient. Kumar did gradually get over being upset by the failure and took up a job in an Auditor’s firm. He worked there for about two years, during which time he cleared both his intermediate and final examinations. He however, continued to harbor the thought that people at the Institute were keeping a watch on him and would not let him progress in life.

He took up employment in the Finance Department of a leading  Software company where he worked for about two years. During this period, he lived away from home in another city and did not kept in regular touch with his family, who were therefore not aware of any change in his behavior. In January 1984 he landed up at home one day saying that he had resigned his job. The only explanation he gave for this was that the people at the Institute of Chartered Accountants were responsible for his resignation. He told them that he would never ever take up employment again. Unable to comprehend his behavior, his family, especially his father,  repeatedly  tried to reason things out with him. He was unyielding.

Gradually, over a period of  two months,  the family noticed that he withdrew from any conversation or socialization. He did not participate in any family activity. He lay awake at nights, poring through  his texts and vigorously writing page after page. He did not let his family see what he was up to, telling them that they had to patiently wait and watch for a miracle! His family however persisted in getting to know what was happening, resulting in his increasing irritability. On one occasion, he beat up his father for “colluding with the Institute to destroy his career”. That was  when, his parents  decided that a psychiatric consultation was needed.

The parents took him a psychiatrist in Chennai and treatment was initiated.  There was a gradual improvement in his clinical condition over a period of 3 months. He soon landed a job in a Finance company. Prior to starting on the job, he purchased a motor bike with the money he had earned in the previous concern. His family was happy with his recovery. He continued to live with his family.

After about 4 – 5 months, Kumar started missing  appointments with his doctor. He would also neglect taking medication periodically. The family did not notice that  he was missing his dosing schedule, since he was regular to work. A day off from work once in a while  also did not rouse any suspicion. However, Kumar gradually stayed away  from work  more frequently. When he did not go to work for over week, his family realized that something was wrong. He refused to tell them anything about his absenteeism. Enquiries at the place  of work, revealed that he had resigned and had also collected all the money that was due to him. The manager at the work place also told Kumar’s father  that  Kumar was noticed to be behaving abnormally for over one month before he resigned. His personal computer at work showed several documents, which were letters charging the Institute of Chartered Accountancy for “conspiring to destroy his career in auditing”. Kumar had given as reason for resignation that he firmly believed that the Finance company was involved with the Institute of Chartered Accountancy in the conspiracy.

When Kumar’s parents tried to coax him to see his psychiatrist, he refused. On repeated persuasion, he reacted violently, beat up his father and broke the television set at home. He had to be forcibly admitted to a private psychiatric hospital for treatment, where he remained for over a month. As he refused to go back home, after discharge, the family rented a small apartment for him, where he lived alone, with daily supervision from his parents, who also monitored his medication schedule. He remained thus for about 6 months. With efforts from his family and a friend, a fellow professional, he took up small accounting assignments at home.  He however refused to go out to work.

There was a rather unexpected turn of events, when his mother suddenly died.  One of Kumar’s siblings observed, “Kumar seems to have lost his capacity to express his emotions. He was very close to Mom, yet did not even react to her death!”  During this period of family crisis,  no one supervised Kumar.  He continued to live in the rented apartment. He refused to take part in his mother’s death ceremonies. The family also left him alone, too busy to supervise him.

He remained apparently well for a while.  One day, the apartment owner complained to his family, that he had not stepped out of the home for  3-4 days, and that the daily newspapers had not been retrieved, and that there was no response to door knocks. The family reached there and forced open the door, only to find that Kumar was sitting in his room, in a daze. The room was in a mess, with papers strewn all over, the personal computer monitor broken  and several packets of partially eaten, rotting food.

Kumar was once again admitted to the psychiatric facility, where he remained for one month. As he could not go back to the rented apartment and the family was in no circumstance to take him home, he  was admitted to a residential facility. He stayed there for one year. He was discharged  from the facility and referred to SCARF Daycare for further management. While at the daycare, he willingly participated in many of the rehabilitation programs. Interactions with his case manager revealed his intense  desire to  start his own auditing firm. He lived with his father during this period.

Six months later, he reported that one of his friend’s wanted his assistance to take on an assignment at Pune. Despite his father’s hesitation, he went to Pune , where he worked for about two months. He remained well throughout this period and was also compliant to medication. He maintained contact with the case manager at SCARF.

As he had continued to be asymptomatic  for about two years, the family decided to get him married. He too was willing and the marriage took place with a lot of grandeur. Soon thereafter, problems cropped up in his relationship with his wife. She charged him and his family of having cheated her, by not telling her that he was under treatment. Inadequate sexual function resulted in the marriage not being consummated. The wife walked out on him , despite counseling by his case manager. Unable to cope with this turn of events,  Kumar relapsed and had to be admitted to the acute care facility once again.

He went home after discharge from the facility, to live with his father. However,  he remained  hostile to his father and communicated very little to his siblings. He also refused to attend SCARF. He took his medicines, with great reluctance. He remained unproductive and did not involve himself in household tasks. He did visit the OP at SCARF for periodic reviews, but was unwilling to attend the daycare.

He relapsed once again about a year later. He was aggressive once again, “because my father is continuously nagging me”.  He became delusional against the parent, whom he blamed for the failure in his career, as well as his marriage.   This time, however, he was admitted to SCARF’s residential care facility at Mahabalipuram. He remained admitted for a year and a half. Over a period of time, he involved himself in all the activities at the facility. Individual Counseling focused on medication compliance. The occupational therapist also focused on the possibilities of  job placement. Efforts were made to contact Kumar’s friend, who was running an auditing firm, even while Kumar was in the center. Kumar’s father was given the task.  The friend agreed to take him on after discharge.

During the period he was admitted, efforts were made to involve the family in the rehabilitation program. The parent and the siblings attended SCARF’s Family education Program at the headquarters. They were also counseled on managing Kumar with focus his medication, his daily activity schedule, a job search and interpersonal interactions.

There was specific focus on his unpredictable violent behaviors.. The family expressed a good deal of reluctance to take him home from the residential facility on account of this. In fact, during the early period of Family Intervention, they were quite insistent of custodial care for Kumar’s life time. During the sessions, the family was educated on how they could identify possible aggressive outbursts early and on how to deal with it.
Kumar was eventually discharged home. He started working at the firm. He visited the out-patient services periodically for reviews. The rehabilitation officer also maintained contact with him regularly. Gradually, he settled down into a routine and was also compliant with medication.

During the past five years, he has maintained well, with no relapses of his illness. Living alone with his parent, he has also taken up a lot of the domestic tasks. Even during a period of family crisis, when his father took  critically ill, he was able to manage well. He relates to his siblings, comfortably. He has been able to achieve a productive status at work and even takes on assignments outside the citys

The man who would not step out: Intervening at home helped!

Mr. Sankar is a 40 year old single man from a middle class family in the city of Chennai. He has completed his 10th grade, and does not hold any job at present. He lives with his brother and sister. His brother, who is also diagnosed as having schizophrenia and is currently under treatment at SCARF, is employed in a private firm. His sister has chosen not to marry so that she can take on the responsibility of caring for her sick brothers. She is employed in a hospital in the administration department. Both of Sankar’s parents expired a few years ago.

Sankar’s problems date back to 1992, when he first exhibited symptoms of intense fear of being arrested by the Police. This fear was precipitated by the assassination of the then Prime Minister of the country, Mr. Rajiv Gandhi. He kept tuning his radio to a particular channel which, he thought would give information about his arrest plans. He broke open the radio, when he could not receive the channel he wanted. In his attempts to get “appropriate “ news, he purchased several radios in a span of two days. He talked of hearing radios sending him messages and became completely withdrawn. He was admitted to a  private nursing home where he was diagnosed as suffering from Chronic Schizophrenia on the basis of a  history of being unproductive for over 10 years. While he had found several jobs over the years, he never stayed for long in any of them, as he would become suspicious of persons who worked with him. Personal care was well below expected norms. He received treatment for the first time in his life. He improved well and treatment was continued for about 4 years, during which time he remained well, although not completely functional. He then gave up medicines but remained well for a few months, during which time  he found a job  in a private concern.

Sankar relapsed within a few weeks of giving up medication and become floridly symptomatic. He became fearful, reported hearing voices, was suspicious about people walking on the roads and refused  to sleep fearing bodily harm.  He was once again admitted to a private nursing home from where he ran away, fearing he would be attacked. He was treated with medication and shock therapy.  Although he recovered and his family was able to  manage him, there were several episodes of angry outbursts. During one of these he even tried to strangle his sister. The family approached SCARF for rehabilitation and Sankar was asked to come to come in for Daycare. He refused.  Though he continued to take medicines, he became progressively withdrawn and by 2004, he had not  been out of home for over 5 years. He believed that people were trying to take photographs of him to harm him. He insisted that the windows in his house remain shut. In fact, he owned no footwear, for he felt he did not need them!During this period his sister kept in touch with the rehab team at SCARF and Sankar was on regular medication.

When we initiated the home based services at SCARF, the team took up the task of reaching out to Sankar and his family. The team visited Sankar at home to evaluate and chalk out an intervention plan. Sankar was initially reluctant to even talk to the team. After several attempts at persuasion, Sankar finally agreed to comply with a list of daily activities that he could carry out at home. The sister was taught to monitor and document his daily activity schedule. The team visited Sankar frequently. He was gradually motivated to go out to the nearby shop and make small purchases. In fact the first time he went out was when James, one of the team members took him to a shoe store to buy footwear!   Progressively, Sankar started going out alone to shop, and took on a lot of household chores.  He was on regular medication during this period. He was receiving Clozapine at bedtime. His drug compliance was good.

He was then encouraged to come in to SCARF for day care, initially once a week, later more frequently, till he eventually agreed to come to the facility everyday. The home intervention team continued to visit his house on the days he did not come for day care. At the center, he found it difficult to interact with other day care attenders. He was therefore permitted to stay by himself and take on the task of making paper bags.

Sankar’s self confidence grew steadily and he got over his fear of interacting with the outside world. He was able to function independently, although he was reluctant to interact with people, whether familiar or strangers. He was regular at the day care centre. His family was very pleased with his improvement and expressed their gratitude to the home team for the change.

Gradually, Sankar communicated his desire to earn a living.  With the help of the team, he found a job in a textile shop, about 10 kilometers away from home. The team first accompanied him for an interview with the owner of the shop. When he was appointed, the team sent him alone with the shop’s address on the first day. Although he was reluctant to travel by  public transport, he was strongly encouraged to do so. He returned, failing to find the shop. The next day, one of the team members, James, met Sankar at the bus stop near his house at Thirumangalam. Sankar was asked to find out the bus which would take him to his work place, Ambathur. After several attempts, he figured out the bus route by himself. In the mean time, James communicated to Asha, the other team member and gave the bus number in which Sankar traveled. Asha met him at the bus stop and showed him various landmarks to identify the shop, which he finally managed to locate. He then started his work in the shop. He continued to commute by bus independently and reached the shop on time. Soon he was given a more responsible position in a godown as a storekeeper.

Within a  week of starting work, Sankar appeared to lose interest. He spoke to the case managers stating that his colleagues were not friendly. He felt lonely and wanted to come back to the day care centre. He was encouraged to continue. However, he stopped going to work without informing his case managers. The team came to know about Sankar’s absence from work in a couple of days when they contacted the shop owner. Despite several attempts at convincing him, Sankar refused to take up any job. He felt that although he had earlier expressed a desire to work, he really had no felt need to work. His family also felt that it was enough if he helped out at home  and took care of himself. He did not really need to earn a living.

Soon, Sankar shifted in with his widowed older sister, who lived  alone with her mentally retarded child. Currently, he helps his sister  by engaging in several household chores, like shopping for necessities, collecting water from the roadside pump, housekeeping etc. He escorts his niece to and from the special school. He does not need to be reminded to visit the barber for a regular haircut. His personal care has improved remarkably. He maintains regular contact with the facility for follow up reviews and prescription refills.

His family is generally happy at the improvement that Sankar has shown. They are satisfied that he participates in house hold tasks A person, who had not stepped out of home, for years, Sankar has substantially recovered and become functional. At the moment, Sankar and his family do not feel the need for him to earn a living.