Mimicking Family Like Attributes to Enable a State of Personal Recovery
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Gopikumar et al. Int J Ment Health Syst (2015) 9:30 DOI 10.1186/s13033-015-0022-x RESEARCH Open Access Mimicking family like attributes to enable a state of personal recovery for persons with mental illness in institutional care settings Vandana Gopikumar1, Kamala Easwaran1*, Mrinalini Ravi1, Nirmal Jude1 and Joske Bunders2 Abstract Background: The convergence between mental ill health and homelessness is well documented, but critical events that precipitate the downward spiral into homelessness, and promote personal recovery remain only partially explored in India. Aims: To explore causative factors of the descent into homelessness, and gain insight into creative and innovative approaches that promote personal recovery, specifically in institutional care settings. Methods: This qualitative study used focus group discussions, detailed personal interviews and anonymised data drawn from patient files. The data were analysed using phenomenological approaches. Results: Findings suggest that besides poverty and deprivation, death of the primary caregiver is a critical event in precipitating distress and a breakdown in the family, leading to a loss of support systems and a sense of belonging- ness, and rendering persons with mental illness homeless. Social affiliations, kinship, congruence between the real and ideal self, and the drive to assume a more powerful identity and/or pursue self-actualisation emerged as key fac- tors aiding personal recovery. In the absence of a family, mimicking its attributes appears to ground institutions and professionals in an ethos of responsiveness and user-centricity, thereby promoting personal recovery. Conclusions: This study highlights the critical need to further explore and understand the nature of distress and descent into homelessness, and gain insight into caregiver strain and strategies that can be developed to reduce the same. It further emphasizes the need to shed light on individual strategies that help pursue wellbeing, and delve deeper into the application of value frameworks in institutions and their role in promoting personal recovery among persons with mental health issues. Keywords: Homelessness, Mental ill health, Recovery based approaches, Family Background deprivations and are susceptible to further vulnerabilities The co-occurrence of mental ill health and homeless- such as substance abuse, cognitive deficits, depression, ness represents a persistent and complex social problem. physical ill health and a heightened risk of committing Persons affected by this phenomenon suffer many losses suicide [1–3]. The World Health Organization (WHO) that result in a compromised quality of life. Homeless describes this group as highly marginalized [4]. persons living with a mental illness experience multiple Johnson and Chamberlain [5] posit multivariate path- ways into homelessness that include the loss of traditional livelihoods, poverty, unemployment, social exclusion, *Correspondence: [email protected] urbanization, changing social institutions (family dynam- 1 The Banyan, 6th Main Road, Mogappair ERI Scheme, Mogappair West, Chennai 600–037, Tamil Nadu, India ics), chronic ill health, poor access to health services and Full list of author information is available at the end of the article out-of-pocket expenditure. Among many critical aspects, © 2015 Gopikumar et al. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Gopikumar et al. Int J Ment Health Syst (2015) 9:30 Page 2 of 8 family breakdown has been widely accepted as a key fac- and the positive wellness trajectory thereafter, qualitative tor leading to an individual’s eventual descent into home- methods were considered well-suited. lessness [6]. In-depth, qualitative interviews (n = 4) and focus A large-scale study conducted in Spain among persons group discussions (FGDs) (n = 23) were conducted with mental health concerns, sought to understand pre- with women who had concurrently experienced a state cipitating factors that led to homelessness. It found that of homelessness and mental illness, and accessed one or participants viewed their pathways into homelessness more institutional and quasi-institutional services at The as multi-causal—financial instability, the breakdown of Banyan (a registered not for profit organisation in Chen- familial and social ties, and mental illness were cited as nai, Tamil Nadu). The FGDs encouraged a spirit of open- critical events [7]. The study used a Stressful Life Event ness and offered participants a safe, transparent and open (SLE) framework in order to determine the relationship space to share their personal experiences. The interviews between such events and homelessness and revealed that and FGDs were conducted by a team of researchers, one almost one out of every three persons had experienced with master’s level training in social work (n = 6), one the death of a first-grade relation (parent, child or inti- with master’s level training in counselling psychology mate partner), and almost two-thirds had experienced (n = 4), one with a master’s in mental health services the death of a family member or close friend. In exam- research (n = 5), and one with a master’s in development ining the causal relationships of the SLEs to homeless- studies (n = 8). The in-depth interviews were conducted ness, economic instability followed by the death of family by a social work practitioner with over two decades of members and close friends feature as prominent and experience (n = 4). Additionally information to nuance essential factors. Feelings of abandonment and rejection subjective descriptions were drawn from clients’ files are also perceived as significant triggers. and from annual client led audits of the organisation’s If family and emerging positive relationships and envi- services. ronments symbolize well-being, we need to understand To gain a better understanding of organisational strat- what exactly they represent. Waldegrave [8] defines a egies that help alleviate distress and promote personal family as any primary intimate group, which through recovery, the researchers sought to explore the ethos blood ties or intentional commitment identifies itself as and value-framework that guided practice. A representa- such. Family and its breakdown have been observed to tive sample was drawn from the implementing team of influence many other dimensions of life as well. Building mental health professionals (n = 8) comprising social positive behaviour that ensures physical and emotional workers, community workers, health care workers, psy- well-being as a result of mirroring positive values [9] is chologists and psychiatrists. cited as one such. Similarly, in families that exhibit dys- functional behaviour such as increased aggression, inces- Location of study and population sant conflict, rejection and coldness, there is a greater This study was conducted among homeless women with risk of psychological problems including aggression, mental illness. They were drawn from a group of clients anti-social personality disorder, anxiety, depression and who accessed mental health services at The Banyan, a proneness to suicide [10–12]. non-governmental organization (NGO) based in Chen- The aim of this inquiry is twofold—to explore fac- nai, in the Indian state of Tamil Nadu. The organisa- tors that lead to a downward spiral into homelessness, tion was established in 1993, as a shelter for homeless and gain insight into critical personal and organisational women with mental health issues. It has since, broadened elements that contribute to the process of personal its scope of work, and built diverse response systems to recovery. address the needs of persons with mental health issues (men, women and children) living in a state of pov- Methods erty and/or homelessness. The range of services include This study employed a qualitative mixed methods design emergency and therapeutic care, rehabilitation and day primarily drawing from phenomenological approaches. care, long-term care (graded levels of support includ- Qualitative studies seek to understand the ‘how’ and the ing shared housing, and group home options), and skills ‘what’ of phenomena and delve in-depth into meaning— development and employment facilitation. The organi- making [13]. Qualitative data-collection techniques can sation aligns itself along the wellness and development be designed to be participant-led, thus facilitating the paradigm, and offers a robust social care programme to creation of a platform to articulate participant-generated supplement clinical care, and currently services a catch- perspectives, meanings and values [14]. Due to the sensi- ment population of approximately 600,000. tive nature of the central inquiry that attempts to capture The researchers sought to select a diverse mix of par- subjective experiences of the descent into homelessness, ticipants based on their current living arrangements, Gopikumar et al. Int J Ment Health Syst (2015) 9:30 Page 3 of 8 socio-economic status, and occupational preference.