A Community-based Service Delivery intervention

One fine summer day 6 years ago, 2 mental health professionals – one a psychiatrist, the other a psychotherapist – were walking along the side of a lake in central Kolkata when they came across a bedraggled and dirty, man scrounging for a meal from deep within the local garbage refuse vats. Right opposite the street, was a Missionaries of Charity office, which provided free meals to the poor every day – and yet, here was this man who would not partake. Questions arose – Who was this man? Why did he refuse help/meals from outsiders? Where did he live? Where was his family/support system? And so on…

Only one answer appeared to adequately respond to the whole plethora of questions: He was a Nowhere Person – a homeless person with psychosocial disabilities lost to the world.

And so upon this fateful day, Iswar Sankalpa was borne with Outreach services – Project Naya Daur.

Initiated in June 2007, Outreach – Project Naya Daur is a mental health intervention project with a difference. It provides care and treatment to a population that is invisible to the rest of society – the homeless persons with psychosocial disabilities..

These people belong mainly to the economically backward and socially marginalised families. They are often seen, in various states of mental distress and physical abuse, around railway stations, bus stands, pilgrim centres and on street corners. They are the ‘invisible people’, separated from and/or abandoned by their families.

It is estimated that there are over 400,000 homeless persons with psychosocial disabilities in India, and amongst these, over 90% have diagnosable and treatable mental health conditions. Naya Daur’s team of mental health professionals works within the Kolkata Metropolis to reach out to a segment of society that the city of Kolkata has forsaken for far too long.

PHILOSOPHY

Who is a ‘Nowhere Person?
Lost within and without, the nowhere persons is a woman or a man with psychosocial disabilities who finds themselves out on the street all by her/himself, with no place to call home anymore.

S/he has to fend for themselves, completely and unabashedly alone – for they are feared and despised by the outside world, for what greater fear is there than that of the dark, the mysterious, the unknown.

With no one to help support them – every day is a struggle for these individuals; and consequently food, hygiene, shelter; the most basic of physical needs, become critical areas of negligence for them.

The nowhere person can be found loitering aimlessly on streets, deep in conversation with themselves or an imaginary someone, sometimes snatching and stealing food from a shop, sometimes scavenging though a garbage dump. Perhaps s/he is wearing the tattered remnants of some clothing article, or a self-made frock, or perhaps even nothing at all, or maybe tattered layers of multiple mismatching clothes on a hot summer day. They may be sitting remotely – not approached by anyone, in fact avoided by most – on a street side; lost in their own world of hallucinations and delusions, they may even rant and rave. Perhaps s/he is guarding her/his bundle of possessions – those small bits of plastic, torn clothes, bottles, etc – through which they now relate themselves to the world; sometimes they can even be found mute and impassable on a busy street corner, no word, no movement. And all this while, through all these moments, they fight, they struggle: with conflicts within and without.

Living in situations such as these allow for them to fall prey to abuse of every kind, at every moment. They are seen as threat to our social living, a menace to our environment, and a risk to our safety. But what about their safety, their living, their rights and dignities?

The wandering nature takes her/him to places far away from her/his known places and s/he ends up here in Kolkata which may be a city in a different state from where s/he belonged.

His illness often reaches a level where his ability to connect with the reality becomes impossible – the hallucinations makes him tread to situations which prove dangerous and even life threatening. For example, roadside accidents are very common for this section – leading to amputation of limbs and even death.

On the street living makes her come face to face with abusers every moment- resulting in unwanted sexual abuse and forced pregnancy and STDs.

He may take to addiction with the little money he would get from sympathetic passerby. She becomes susceptible to physical illness which remains untreated.

He happens to suffer from dog bites, wounds and cuts which he is not in a position to look after or even realize the pain owing to psychosocial disability.

Even if she musters courage to ask for help, it falls to deaf ears as no one would come near her owing to the odorous and mutilated wound.

He cannot even remember his name and thus reuniting him with his family seems very difficult.

They are Nowhere Persons, because in India, the entire public healthcare and related support systems depends on the institution of the family. An individual is defined by their familial status; that is, in cases of medical treatment their family name and address is compulsorily required to even admit a person. This would not be much of an impediment for the average family-bound person, however, for a homeless person with psychosocial disability, this criteria is tantamount to scaling Mount Everest. For this person, with no recollection of name or address, getting admission into a hospital or even availing basic healthcare thus becomes near about impossible. In such cases how can a HOMELESS PERSON WITH PSYCHOSOCIAL DISABILITY be expected to avail the most basic of rights, that is, healthcare?

Homelessness and Psychosocial Disability –

Iswar Sankalpa chose to work with the homeless persons with psychosocial disabilities – a population so marginalised that they are only referred to as vagrants in laws drafted in the 19th century with no mention in the current national developmental agenda – not even on paper.

To see and experience the appalling conditions under which this section of society exist has a profound impact upon us. Our natural reaction is to want to rectify the horrors of what we see with a quick, bold stroke. But for the chronically psycho-socially disabled, homelessness is a complex problem with multiple causative factors. In our analysis of this problem we need to guard against settling for simplistic explanations and solutions. We have to look at what conditions these persons must face in the community, what needed resources are lacking, and the nature of the disability itself.

Given the complexity of this populations’ health and living conditions – For a health issue where progress is dependent on innumerable factors, difficult to measure objectively, and where one step forward could be accompanied by two steps backward, a lot of work had to go into coming up with a holistic and empowering project model which would contribute to their over-all well being.

Dealing with the ultra-marginalized is not just ideological posturing from a human rights platform; it makes sound developmental sense. Mental health and illness and related psychosocial disabilities and homelessness are two pervasive issues that societies need to urgently address, for both have a negative impact on the lives of individuals and communities.

Mental health is a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community. In this positive sense, mental health is the foundation for individual well-being and the effective functioning of a community.

While there is no causal link between poverty and psychosocial disability, the two states can feed into each other – while poverty and its attendant stressors are a breeding ground for psychosocial disability, and untreated mental health conditions can lead individuals and families into unemployment, social alienation and poverty.

Given the nowhere

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persons’ vulnerability, the society’s rejection of him/her and the connected issues of poverty and lack of government intervention – it made sense to bring the community together in working with the homeless persons with psychosocial disabilities.

By working in the very place on the streets where this population has made their home involves working with the surrounding community, the law agencies, and the government bodies and bring together public and private services to finally sit up and pay attention to these long neglected and forgotten people.

CARE DELIVERY MODEL

The lonely farm, the crowded street,
The palace and the slum,
Give welcome to my silent feet
As, bearing gifts, I come.

Last night a beggar crouched alone,
A ragged helpless thing;
I set him on a moonbeam throne —
Today he is a king.

Last night a king in orb and crown
Held court with splendid cheer;
Today he tears his purple gown
And moans and shrieks in fear.
Extract from ‘Madness’ by Joyce Kilmer

Project Outreach – Naya Daur works through a unique mental health delivery model – created with public and private institutions and individual participation. We are working through a network of resources which includes the state agencies, NGOs, CBOs, the media, and the community.

Why take the path less travelled?

Working with the homeless persons with psychosocial disability is relatively virgin territory in India, and the organisations that do so follow an institution based model. Initiated in June 2007, Project Outreach – Naya Daur, Iswar Sankalpa’s flagship programme, is a sustainable community based care and support programme for the homeless persons with psychosocial disability in the metropolitan areas of Kolkata – a programme that weaves together state, private and community into a network of resources that not only cares for this forgotten population, but works towards making them productive members of families and community.

The Naya Daur model is based on the organisation’s aversion to the practice of uprooting and institutionalizing people in the name of medical service – a practice that is neither cost-effective nor dignified, and renders restitution and habilitation that much more difficult. Contrary to popular perception, people who have psychosocial disability do possess the ability and right to self-determination and autonomy, and even homeless people, though needy, possess self-dignity and a sense of belongingness – belongingness to their particular corner of the pavement, to the few tattered clothes and titbits that they possess, and to the people around them.

While the organisation offers alternate forms of living and treatment, it allows for individual choices, and adapts its support according to individual preferences and needs. The belief that intervention, medical or otherwise, should be kept at the minimum level, with minimum disruption of a person’s life ensures that treatment and support is provided to the extent that is desired and accepted by the person concerned, while trying not to subsume his or her existential self under the rubric of modern psychiatric and developmental discourse.

By including neighbours and local communities, the organisation garners local resources as well as works towards reducing the stigma against mental illness and persons with psychosocial disability pushing individuals and families into unemployment, social alienation and poverty. The community-based treatment and care model is based on an analysis of the considerable gaps in mental health service delivery in West Bengal, made more complex in the context of homelessness, has been designed to:

Apart from being cost-effective the model, by making institutional stakeholders, especially the government, take responsibility for the health and development of a vulnerable group of people, can become sustainable in the long term. Through its community based model, Iswar Sankalpa hopes to elicit and understand the meaning of ‘madness’ in local cultural contexts, and to bring them into its theorization and practice. The organisation believes that a different concept of mind – its health, its pathology – born out of community experiences, perceptions and cognitions can help evolve a more viable and sensitive notion of community care in the field of mental health. In the long run, the organisation hopes to offer an alternative model of understanding of mental distress as well as care giving for the distressed – alternate to what is being taught and practiced in hospitals and extension clinics, the latter often contributing to pathologization and marginalization of human beings. The successes of the Naya Daur programme have been modest, yet by offering at least a modicum of support and medical treatment, however imperfect, to the homeless persons with psychosocial disabilities, Iswar Sankalpa believes that it has taken some critical steps towards a creation of a humane and respectful environment for those suffering from mental disorders.

Core Activities –

  • A pilot study in 2007 initiated the process of identification and mapping of homeless persons with psychosocial disabilities on the streets of Kolkata
  • IS has a team of trained social workers assigned to different areas of the city to identify homeless persons with psychosocial disabilities and start building a relationship with them slowly in order to be able to provide intervention to them. We get referrals by concerned citizens and organisations who are aware of our services
  • The Kolkata Police have been increasingly involved in the project and are key partners is identifying people needing care, and are a necessary part of the legal process involved in taking care of persons on the streets.
  • Referrals are also done by concerned citizens and communities and other organisations that IS has worked with, and subsequently generating mental health awareness
  • Once the person agrees, the team psychiatrist assess the clinical needs of the client, and our social workers assess their support needs and locates community resources to take care of the person
  • The social worker assesses how the client gets their daily hygiene needs and if s/he is involved in any work and often tries and identifies a caregiver from the surrounding community who has volunteered to care for the client – through various ways – proving daily medicines, providing food, involving him/her in some work, providing a shelter for the night amongst other things. These community caregivers are ordinary people, struggling to make ends meet in their own lives.
  • The psychologist visits every identified client on the streets to provide counselling support
  • In cases where the patient is in a critical condition, our Emergency Response Unit has a specialized multidisciplinary team to deal with the immediate crisis and transfer the patient to the appropriate agency.
  • Our medical camps and awareness meetings help to identify more clients and also to educate the local community on mental health related issues
  • In cases where the clients show interest, they visit the Drop-in Habilitation Centre to engage in rehabilitative activities and work on increasing their functionality by engaging in basic living skills related activities and cognitively enhancing tasks
  • The goal of the project is to be able to empower every client to be able to foster an independent living – by involving them in rehabilitative activities – some clients are able to give their family and home details leading the Restoration team to locate families and reunite them with their lost family member. This is done in collaboration with the Kolkata Police and other government agencies
  • In cases where the family or client is unwilling to live together, the team tries and helps resettle the person in the community itself – by helping them find supportive employment and working towards basic financial independence

OUTCOMES

The Outreach programme started in 2007 and since then has reached out to many of the wandering homeless persons with psychosocial disabilities. As Project Naya Daur is Iswar Sankalpa’s flagship programme, the organisation was learning the ropes at the same time

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as the Outreach programme was expanding its reach. In the beginning, the focus was only on delivering services and providing care to this nowhere population. Hence, the figures in the first few years were not kept on a regular basis and hence when presented, will not be able to give a wholesome understanding of the work done.

However, starting 2009 documentation has been an integral part of the community care programme–

  • 2007-2009
  • Number of persons indentified – 709
  • Number of beneficiaries from the programme – 120
  • Number of emergency cases – 87
  • Number of awareness camps – 46
  • Number of advocacy meetings – 5
  • Food distributed – 825 times
  • Clothes distributed – 605 times
  • 2009-2010
Activities Total
No of persons identified 222
No of persons provided intervention 398
No of persons under follow up 342
No of persons who received emergency treatment 20
No of referral cases 48
No of restoration cases 15
No of nutrition 592
No of clothes 434
No of hygiene care 514
No of awareness camp done 21
No of Participants 1016
No of advocacy meeting 4
No of participant in adv meeting 143
  • 2010-2011
Activities Total
No of persons identified 183
No of persons provided intervention 685
No of persons under follow up 368
No of persons who received emergency treatment 9
No of referral cases 32
No of restoration cases 89
No of times nutrition provided 1248
No of times clothes provided 824
No of times hygiene care provided 1176
No of awareness camp done 20
No of participants 657
No of advocacy meetings 3
No of participant in advocacy meeting 85
  • 2011-2012
Activities Total
No of new persons identified 64
No of drop-outs from programme 59
Re-entry into the programme 7
No of visits by the psychiatrist 60
No of health check-ups in total 495
Restored to family 1
No of persons engaged in supportive employment 40
No of cases referred to government hospital 162
No of persons who received emergency treatment 9
No of times nutrition provided 848
No of times clothes provided 577
No of times hygiene care provided 1063
No of counselling sessions 761
No of awareness camps done 20
No of participants in awareness camps 640
No of advocacy meetings 2
No of participants in advocacy meetins 207
  • 2012-2013
Activities Total
No of new persons identified 112
No of drop-outs from programme 52
Re-entry into the programme 10
No of visits by psychiatrist 134
No of health check-ups in total 701
Restored to family 7
No of cases referred to government hospital 108
No of cases referred to private hospital 4
No of persons who received emergency treatment 8
No of times nutrition provided 832
No of times clothes provided 526
No of times hygiene care provided 948
Medical camps 1
Counselling sessions 749
No of awareness camps done 24
No of participants in awareness camps 733
No of advocacy meetings 1
No of participants in advocacy meetings 27
  • 2013- 2014
Activities Total
No of persons new identified 55
No of drop-outs from programme 26
Re-entry into the programme 10
No of visits by psychiatrist 163
No of health check-ups in total 386
Restored to family 2
No of cases referred to government hospital 78
No of cases referred to private hospital 5
No of persons who received emergency treatment 7
No of times nutrition provided 515
No of times clothes provided 345
No of times hygiene care provided 503
Counselling support 525
No of awareness camps done 20
No of participants in awareness camps 335
No of advocacy meetings 1
No of participants in advocacy meetinsgs 47
  • 2014 – 2015 (Till September 2014)
Activities Total
No of persons new identified 42
No of drop-outs from programme 19
Re-entry into the programme 4
No of visits by psychiatrist 357
No of health check-ups in total 245
Restored to family 3
No of cases referred to government hospital 179
No of cases referred to private hospital 2
No of persons who received emergency treatment 4
No of times nutrition provided 510
No of times clothes provided 315
No of times hygiene care provided 570
Counselling support 362
No of awareness camps done 13
No of participants in awareness camps 414
No of advocacy meetings 0
No of participants in advocacy meetinsgs 0

CHALLENGES

Outreach – Project Naya Daur is a community-based intervention model which provides services to a person in a social environment that is fraught with deprivation, uncertainty and unpredictability. The very premise of the project entails facing challenges in its implementation.

  • Some clients unknowingly get carted off by the Vagrancy Department street raids to the city vagrancy home, where they are left to suffer in anonymity, silence and indefinitely. More frequent visits to the vagrancy homes and greater mutual communication with the Vagrancy department is required on part of Iswar Sankalpa to ensure our clients safety and well being.
  • Clients going missing from their ‘home on the street’; which is unfortunately a part and parcel of the nature of homelessness, drifting and wandering. A greater degree of vigilance is required on part of the Iswar Sankalpa outreach team, as well as on the part of linkages with the Kolkata Police, to ensure that clients within the purview of our programmes are monitored more efficiently and rigourously.
  • Mental health and related conditions are generally often misunderstood by the individual, family and consequently by the society on a whole. The poor and incomplete knowledge often leads to attitudes leading to discrimination and stigma faced by the person with the psychosocial disability and their families. Often families turn away from the individual, leading him/her to their own devices, without care and to a more debilitating disability.
    Myths surrounding mental health related conditions often lead to magico-religious practises creating a complex negative cultural connotation in the society.
  • Psychosocial disability – if left without any intervention and care at an earlier stage often leads to a chronic state of disability which is further intensified by the related intra-psychic, inter-personal and environmental conditions.
  • There is a lacuna in the judiciary, social welfare department and health department regarding mental health services.
  • Lack of government facilities at policy and implementation level often compounds the access to healthcare by this population. There is an acute absence of adequate and holistic institution, shelter and transit care based services, which aims at integration of the individual into the society and often leads to further alienation. Hospitals have become dumping ground for families who do not understand these mental health issues and government apathy to this urgent need of healthcare leads to people languishing for years in whatever available facilities, forgotten by the world outside.
  • The segregation of mental and physical health institutes – is a catch 22 situation – persons with psychosocial disabilities are not welcome in medical hospitals, and psychiatric institutions are not equipped to deal with physical problems, despite the fact that physical and mental health conditions often exist in a co-morbid state for many of the persons having psychosocial disabilities. In addition, the entire public healthcare system depends on the institution of the family. So the family name and address is needed to even admit a person. In such cases how can a homeless person with psychosocial disability be expected to avail of healthcare?