Tracing the development of psychosocial rehabilitation from its origin to the current with emphasis on the Indian context.

Mental illness and mental health are concepts that have existed from time immemorial. In India, the Atharvaveda and Vedic texts and traditional medical systems such as Siddha, Unani, and Ayurveda have described mental health and disorders, in detail. The advent of the mental hospital brought in the 'chemical revolution' in psychiatric management. The early nineties witnessed the birth of psychiatric rehabilitation in India. These developments saw a shift from a biological to a biopsychosocial model. It embraced the individual, family, community and society into the treatment process. The present rehabilitation process is geared towards providing quality of life, community living, accessible and suitable care.

-Ken Kesey, One Flew Over the Cuckoo's Nest

Mental illness and mental health are concepts that have been existent from time immemorial. The history of mental illness and the trajectory of psychiatric care have been through the dark and despondent, superstitious, and stigmatized, radical and resourceful, experimental, and empirical. The first stirrings of the mental health movement began in Greece, Jerusalem, and the Islamic world in the 4th century AD, slowly spreading to the rest of the world. India, a land of diverse cultures, was no stranger to the concepts of mental illness and more importantly, mental health. The Atharvaveda talked about divine curses, and mental disorders were described in the Vedic texts. Traditional medical systems such as Siddha, Unani, and Ayurveda also described mental health in detail.[1]

By the 18th century, “lunatic” asylums were set up across continents. This was an era of institutionalization where people with mental illness were kept in asylums for psychiatric treatment and kept away from family and society. The underlying assumption was that they posed a danger to self and others. The concept though started with the sentiment of modernizing psychiatric care had several drawbacks, namely, use of restraints, abuse, unhygienic conditions, poor nutrition, and overcrowding. The prevailing condition of the time led to the development of the humane care approach toward the late 19th and early 20th century with influential and leading names in psychiatry paving the way for better care.[1]

The British Raj saw the setting up of several mental asylums across India. These asylums cropped up in major cities such as Calcutta, Madras, and Bombay.[1] Some of them, like their Western counterparts, also saw a period of chaining, unscientific procedures, inhumane treatment, and overcrowding while others had started implementing rehabilitation practices involving psychotherapeutic inputs and involvement of local communities in psychiatric care.

The advent of the “mental hospital” began with the establishment of the Government Mental Hospital, Kilpauk, Madras whose ancestry traces back to more than 200 years. The 1950s was considered a landmark for the hospital wherein it saw a revolution in the treatment of the mentally ill. It was a “chemical revolution” in psychiatric management, with the introduction of antidepressants and anxiolytics. The practice of psychiatry became more humane and modern.[2]

In the year 1922, it was recognized as a “Government Mental Hospital” in keeping with the developments being made in the field of psychiatry. The hospital made great strides in achieving an ideal “doctor–patient” relationship and brought in “voluntary board admissions” that modified the application of the Indian Lunacy Act, 1912, setting a precedent for others to follow. The “open hospital” system was introduced which facilitated the removal of physical restraints; psychiatric outpatient clinics were introduced in two general hospitals of Madras, thus, promoting referrals and reducing overcrowding in the mental hospital. The Indian Red Cross Society started a 12-month course in social work at the hospital to improve patient care.[2]

The Central Institute of Psychiatry, Ranchi was set up in 1922 which set the foundation for psychiatric rehabilitation in India. Down south, the All India Institute of Mental Health was established at Bangalore in 1954. It soon became the National Institute of Mental Health and Neurosciences in 1974.[1] In the quest for scientific research and streamlining services for the mentally ill, training programs were launched with the aim of introducing trained personnel in psychiatric care. These developments were harbingers of change and brought with them a change in mood from a biological perspective to a biopsychosocial model.

The biopsychosocial model has rehabilitation at its core. The focus shifted from the ill person's limitations to the strengths of the person instead. The process focused on creating opportunities for individuals with mental illness to reach an optimal level of functioning and independence. For the first time, there was a move to address not only the person's individual symptoms and capacities but also to address the role of the environment in influencing the progression of the disease. The model brought in the family, community, and society into the treatment process. This was an era of change from custodial care to the birth of rehabilitation psychiatry in India.[3]

In another part of the world, post the I World War, the inclusion of individuals with psychiatric disabilities into vocational rehabilitation programs with the US and British governments extending financial assistance, provided legitimacy to the idea of training, and rehabilitating people with psychiatric disabilities. The psychosocial rehabilitation movement grew out of the realization that most persons with severe mental illness’ rarely experience a full return of psychosocial functioning in the community. Nonprofessionals and patients themselves initiated psychosocial self-help clubs located in cities where the mentally ill congregated in large numbers. Early clubs such as Fountain House and Horizon House were founded by groups of ex-patients for mutual aid and support.[4]

The rehabilitation movement in India was initiated by the need for deinstitutionalization and providing persons with psychiatric disabilities, the opportunity to work and live in the community. The field of psychiatry was fast arriving at the conclusion that it was dealing with people who were more than the sum total of their psychiatric disorder. The field required impetus to meet the cognitive, emotional, social, and environmental needs of the person. The focus drifted from an illness model to that of functional disability.

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEUROSCIENCES DPNR SERVICES

Occupational therapy as a service was provided to persons at the All India Institute of Mental Health. The Department of Occupational Therapy, Retraining and Rehabilitation took root in 1954. Occupational therapy was provided to the patients of the hospital till 1977 and later called Occupational Therapy Department. Dr. P. S. Gopinanth headed this unit and brought into focus the importance of this form of therapy as an adjunct to traditional medication model to treat the mentally ill. Later, Dr. T. Murali brought structure to the department and brought it to greater heights, which was seen as a model to emulate across the country. In 1986, both the psychiatric and neurological rehabilitation services were combined under the Department of Psychiatric and Neurological Rehabilitation, better known as DPNR services.[5]

Rehabilitation services can be classified under four main models of intervention – Recovery, Respite, Rescue, and Retention. These models continue to be relevant in modern psychiatric care. The aim of the recovery model is to empower persons with mental illness to function in their daily lives, restore their self-esteem, and improve the overall quality of life. The model is geared toward individuals who have shown improvement in their psychiatric illness and are ready to undergo rehabilitation and retraining and assume social roles. The respite model is largely for clients who are clinically stable but have residual symptoms, mild-to-moderate disability, and who have difficulty returning to preillness level of functioning. The rescue model reaches out to the clinically unstable, wandering, and homeless mentally ill who suffer from moderate-to-severe disability and is carried out under the aegis of community-based initiatives. The retention model utilizes minimal staff intervention to provide help to those whose families are not very supportive or not engaged with their treatment and at times offers respite to families. These models provided the start for several halfway, group and long stay homes and community outreach programs to be initiated.[6]

The idea for the Medico Pastoral Association began in 1962 under the care and supervision of a doctor-clergy group. One of the founding members of the Association was Dr. Joyce Siromoni, a gynecologist by profession. In 1972, the Medico Pastoral Association was registered and run under the constant care of doctors, social workers, clergymen, and lay public. They started a halfway home to provide a home for patients recently discharged from mental hospitals. The aim was to provide them with a therapeutic environment which would facilitate better integration into families and the workplace.[7]

Antara, a center located in Kolkata, was set up for the psychiatric treatment and rehabilitation of persons with mental illness especially persons with substance use problems since 1971. The main services offered are treatment for alcoholism and drug addiction and counseling for substance abuse. The main founders of the organization were Dr. Satrujit Dasgupta, Dr. R. B. Davis, Mr. P. M. John, and Bro. Andrew and Blessed Mother Teresa, Missionaries of Charity, Calcutta.[8]

The Schizophrenia Research Foundation (SCARF), a nongovernmental organization (NGO) in Chennai was founded in the year 1984 by a group of philanthropists and mental health professionals. The organization was led by Dr. M. Sarada Menon, a psychiatrist, and being currently led by Dr. R. Thara, Director of SCARF. They have been meeting the rehabilitation needs of people through a multidisciplinary team comprising of psychiatrists, psychologists, social workers, and rehabilitation professionals. They have also been credited with conducting extensive research in the field of mental health.[9]

In 1959, Ms. Elly Jansen started a halfway home in Richmond and became the founder of Richmond Fellowship, UK. In Bengaluru, she helped in the start of the first halfway home “VIKAS” in 1986. Later, the “Asha halfway home” was started in 1989. The goals for rehabilitation were designed for the care and welfare of persons with severe psychiatric disorders. Some of the founding members of were Ms. Elly Jansen, Dr. Narayana Reddy, Dr. Channabasavanna, Mr. M Krishnamurthy, and Dr. Prakash Appaya.

The Richmond Fellowship Society, Bangalore Branch also runs a long stay home and a Daycare center that offers vocational training. It operates branches in Delhi, Lucknow, and a rural branch in Sidlaghatta, in rural Karnataka. It functions on the Therapeutic Community model and has been spearheaded for the past 27 years under the able and keen guidance of its Honorary Secretary and CEO, Dr. S. Kalyanasundaram.

Aasha is a registered nonprofit NGO in Chennai founded 1989. It is run by families of persons with mental illness. Dr. Sarada Menon was instrumental in the starting of the same. Aasha manages a rehabilitation home, provides vocational training and supported employment and conducts advocacy and stigma reduction activities. It also provides a platform for caregivers to support each other and learn coping strategies to care for their loved ones.[10]

Dr. Joyce Siromoni went on to support the cause of marginalized women on the street who suffered from mental illness. In 1991, she was instrumental in establishing Paripurnata, a halfway home, a first of its kind in Calcutta. Paripurnata's work centers on marginalized mentally ill women, and their mission is to strive for mainstreaming the women into society and to restore their rights and dignity.[11]

The rehabilitation movement also saw the creation of family groups who came together to look after their ill family members. One such facility established in 1992 was the Family Fellowship Society, started by Dr. Ranganathan, a psychiatric social worker by training along with the families of mentally-ill. They have played a pivotal role in advocating the “self-help” movement on the part of the families on the lookout for alternative care services.[12]

M. S. Chellamuthu Trust and Research Foundation, an NGO, was founded in the year 1992 in Madurai by Dr. C. Ramasubramanian, a psychiatrist. It was started to provide services for the care of persons suffering from mental illness as well as promote mental health. They run several rehabilitation programs for mental health promotion as well as mental health literacy and advocacy.[13]

The Banyan was started in 1993 by Ms. Vandana Gopikumar, a psychiatric social worker and her friend and colleague, Ms. Vaishnavi Jayakumar, an MBA graduate. It started as a shelter and transit home for women who were homeless and mentally ill and were living on the streets. Today, they are involved in the expansion of rehabilitation activities, developing family support, awareness campaigns, networking, and working toward policy change in the mental health field.[14]

Ashadeep was founded in 1996 at Guwahati by Mr. Mukul and Ms. Anjana Goswami, caregivers to a person suffering from schizophrenia. It was started with the aim of providing mental health services and psychosocial rehabilitation to persons with mental illness. They also work with women who are homeless and mentally ill to reintegrate them back into their families.[15]

Action for Mental Illness (ACMI) India, a NGO, was founded in 2003 to advocate for the rights and needs of persons with mental illness. The architects behind the same were Dr. Nirmala Srinivasan, a caregiver and disability activist and Director and Trustee, ACMI and Mrs. Laila Ollapally, an advocate at the Karnataka High Court. ACMI advocates for policy, legal and service delivery issues relating to mental illness. ACMI has also launched Families Alliance on Mental Illness for families to build awareness, advocate, and take action. ACMI and AMEND, also a self-help group of family caregivers in Bengaluru, have done immense service in bringing together family caregivers.[16]

The Chittadhama Trust was founded by Dr. Swaminath, a psychiatrist by profession and a few of his colleagues to provide residential care and rehabilitation for homeless persons with mental illness in 2010. It was started at HD Kote in Mysore district with the help of a group of psychiatrists, psychologists, and psychiatric social workers. The Trust also makes conscious efforts to reunite the rehabilitated persons with their families.[17]

In recent times, the goals of the rehabilitation process are geared toward providing quality of life, community living, and suitable care which is affordable, accessible, and committed. The care is provided by a multidisciplinary team consisting of members representing different fields of psychiatric care. Rehabilitation centers have over a period through their various programs shown significant improvement in psychiatric disabilities such as self-care, communication, interpersonal relationships, vocational activities, family relationships, and participation in community and leisure time activities.

George Bernard Shaw said, “progress is impossible without change.” Through the years, the field of rehabilitation psychiatry has been through its ups and downs. The mental health field is steadily incorporating psychiatric rehabilitation as an essential component of the management of persons with chronic mental illness. The awareness that the interventions must include both the patient and the caregiver has led to the development of various psychoeducational programs, advocacy groups, research studies, anti-stigma campaigns, and community outreach programs to provide holistic, tailor-made, and culturally appropriate treatment and management. Over a period, the field had made great strides but the process is an ongoing, arduous one and a lot more is yet out there to discover, innovate, and create.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

This article records the histories and the people involved in some of the rehabilitative efforts across the country. While it is by no means an exhaustive list of the varied and diverse endeavors, what it does is to gesture towards the sheer diversity of the efforts, ranging from the planning of shelter to the destitute mentally ill to the provisioning of activity schedules at the half way home facilities. It also highlights the fact that while formal institutional rehabilitative effort is a relatively recent concept, the thinking about rehabilitation is part of the thinking that was very much a part of psychiatric intervention even in the days of the much-vilified mental hospital. What perhaps needs to be a matter of further discussion and research is an understanding of numbers to see what percentage of the people who need help are actually getting it, because the ground reality is that, despite this variety of approaches and efforts, these endeavors form perhaps a small drop in a rather large ocean.