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VANDANA GOPIKUMAR

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India,

Vandana Gopikumar has successfully demonstrated that one can develop treatment, care and rehabilitation strategies for mentally ill homeless women, using the community care approach, both in urban and rural areas. Vandana’s model has been widely and independently replicated, and has laid the foundations for her endeavours in building a cadre of non-specialized mental health work force to transform the standards of treatment in India.

This profile below was prepared when Vandana Gopikumar was elected to the Ashoka Fellowship in 2012.

INTRODUCTION

Vandana Gopikumar has successfully demonstrated that one can develop treatment, care and rehabilitation strategies for mentally ill homeless women, using the community care approach, both in urban and rural areas. Vandana’s model has been widely and independently replicated, and has laid the foundations for her endeavours in building a cadre of non-specialized mental health work force to transform the standards of treatment in India.




THE NEW IDEA

Eighteen years ago, a 22-year-old Vandana set up a shelter for homeless mentally ill women in order to provide care and basic treatment, and she was struck by the realization that the problem was much deeper since India lacked an effective overall mental healthcare system. Furthermore, she saw that the homeless mentally ill required not just medical attention but a whole spectrum of healthcare and psychosocial services ranging from their rescue off the streets to rehabilitation, reintegration into society, while also ensuring a continuum of care. 

With a determined focus on overall wellness as opposed to symptom reduction alone, and the strong participation of the community, Vandana has designed a microcosm of a full bouquet of solutions for the homeless mentally ill, with the goal of ensuring their reintegration as functional members of society. Having tested and honed her healthcare delivery system in and assisted in its replication by other citizen organizations (COs) in different states, Vandana has begun to be strategic in influencing government machineries to adopt her methodologies on a national scale. She has effectively engaged the government and policymakers to redesign standards of treatment and budgetary allocations for mental health, on a national level. As a member of the Policy Group on National Mental Health Policy and Plan, appointed by the Ministry of Health and Family Welfare, Vandana also advocates for openness and humane practices in treatment centers that offer long-term care for the mentally ill.

Vandana believes rural areas are a point of origin to ebb homelessness due to mental illness. She is working with the Panchayats communities and the Central Government to make facilities available for early screening, counselling, and treatment for mental illnesses at Primary Health Centres in villages. As a result of her efforts, fewer individuals may be rendered homeless as a result of undetected and untreated mental illness. She is also addressing the issue of a lack of trained mental health professionals in India, by creating integrated courses in partnership with reputed universities, to train professional and non-specialist social workers in the field of psychiatric social work. Vandana is working with the Central Government to place these social workers in both urban and rural areas, to ensure quality of treatment and care across the country. 




THE PROBLEM

In India healthcare delivery for mental health is largely institutionalized; healthcare is delivered to those who actively seek it, and can afford it. These models employ a bureaucratic, top-down approach and are heavily dependent on psychiatrists, with a focus only on symptom reduction. Further, India only has about 2,500 psychiatrists for its 1.2 billion population—most of whom are concentrated in certain urban pockets thus, the homeless mentally ill populations, who neither have family support nor the consciousness to seek care, are not recipients of these services. Furthermore, government mental health institutions do not have a system of retrieving these people from the streets, or assisting in their family reintegration once treatment is complete. Due to a lack of understanding about their conditions or the unavailability of space to care for their unique needs, most “wandering” mentally ill are sent to Beggars Homes instead of being taken for treatment by the police or other state authorities. 

While there has been a rise in COs employing community-based approaches for the care of the mentally ill, it requires the patients to approach healthcare providers for treatment. Also, existing models of care are heavily dependent on caregiver/familial support to assist them through their recovery and ensure long-term treatment adherence to prevent relapses. This approach fails in the context of homeless mentally ill as they lack critical caregiver/familial support. Additionally, when combined with their tendency to wander, a symptom associated with some mental illnesses, treatment may be disrupted and incomplete. These existing challenges are amplified and more complex in the context of homeless mentally ill women, who are subject to greater neglect and sexual abuse. 

Homelessness is largely an urban phenomenon. Mentally ill persons found wandering in urban areas, in most cases, have wandered away from their homes in rural areas, or in some cases are abandoned by their families. This happens largely because about 80 percent of the rural population have no access to mental health services despite the government-instituted National Mental Health Plan (1982); to integrate mental health into the public health agenda. Further, having travelled long distances from their homes, they are typically found at transit points like railway stations or bus stops, which makes it harder to identify them or trace their families.




THE STRATEGY

Vandana set about creating community-friendly, holistic solutions for effective mental healthcare delivery to both urban and rural populations in Tamil Nadu. She seeks to transform mental health infrastructure, through policy reform, and is devising courses in partnership with universities and the government for the training and placement of professional and community-based mental health managers across the country. 

Through The Banyan, Vandana has designed a mental healthcare delivery system that is designed to address the complex mix of mental illness and homelessness. To cater to the specialized nature of challenges among the homeless mentally ill, The Banyan proactively seeks them on the streets and brings them into their fold for treatment. To assist in its efforts, the Banyan has created a network of partner organizations, law enforcement agencies, and citizens who refer women to its premises. To respond to emergencies from the community, The Banyan set up a central emergency care center (a 200 bedded hospital) and an outpatient service centre in Chennai, Tamil Nadu. By providing women with a safe space, food, clothing, and basic care, the staff of The Banyan establish a relationship of trust—the first step toward their healing process.

Operating out of a nodal Transit Care Centre that houses homeless mentally ill women, The Banyan has designed a medical-socio model of healthcare delivery, focused on medical treatment as well as therapy-based care, and individual development. Psychiatrists and psychologists closely monitor the stages of recovery, and incorporate the learning of life-skills as an integral part of the process. The Banyan has introduced a unique concept, the Growth Lab, in which a client in more advanced stages of recovery performs everyday activities. Under supervised conditions, they mimic daily living chores to prepare them to rejoin families. 

Recognizing that relapse is a common consequence and continued care is critical, particularly for the homeless who often go back to a life on the streets, the Banyan has designed a comprehensive reintegration and aftercare program. It focuses on tracing families of clients, assisting them with their travel and relocation, and creating opportunities for localized aftercare. Families are also provided with a disability allowance to ease their financial burden. Women unable to rejoin their families, live in self-help groups. Identifying complementary skill sets and needs, The Banyan assists women to live together as a family unit, in homes they procure on a rented basis, to offer each other companionship and support. To ensure financial self-sustainability and build their skills and confidence, vocational training and creating job opportunities has been critical to restoring normalcy and independence into the lives of these women. 

For the first time in India, Vandana has also set up a long-term care center for impoverished mentally ill women, called Protected Community, that recreates community-based living and promotes openness and autonomy in a structured environment. This approach is changing perceptions and influencing how others design institutionalized mental healthcare. The Central Government is in the process of allocating budgets and designing processes to replicate this model in other parts of the country. Vandana’s series of interventions from rescue and emergency care to vocational training and aftercare support, are aimed at enabling homeless mentally ill women to reclaim their identities as functioning contributing members of society. So far, the Banyan has rescued more than 1,500 women from the streets, and over 1,000 women have been successfully reintegrated into society.

The Banyan has also instituted a Human Rights Cell at its premises, the first of its kind in mental health centers. This ensures accountability and addresses possible incidents of human rights violations by the staff against patients. To ensure easy access to justice and avoid long hours of court appearances and cumbersome paperwork, The Banyan has been successful in instituting a Lok Adalat—the world’s first permanent and continuous court specifically for those with mental illness, on its premises. 

After being initially invited by a premier college in Chennai to run mental health clinics in urban areas with high incidence of suicides among young people, Vandana discovered that mental health services for the general population was minimal, and largely restricted to mental hospitals. To respond to this dire need, The Banyan set up community mental health care centers in the city of Chennai to reach out to larger sections of the general population. Functioning as an outpatient clinic, it includes a psychiatrist, a psychologist, a social worker, a counselor, and a pharmacy. This clinic offers both medical treatment and a psychological support-based model. Currently two centers operate in Chennai, which treat patients from all over the country. The approach focuses on holistic patient care and delivers it in non-threatening surroundings. For example, one health center is located at a premier university, as the stigma surrounding mental illnesses persists and often dissuades people from seeking treatment.

Observing that most mentally ill women came to cities from rural areas, Vandana sought to put in place systems-changing mechanisms that ensure that the issue is being plugged at its root. The Banyan has spread its community mental health care initiatives to a large full service rural center at Kovalam, in Tamil Nadu. This move was made to serve the dual purpose of reaching out to clients in rural areas and understanding the functioning of the District Mental Health Programme so as to make informed recommendations to the State Government of Tamil Nadu on what would serve as a functioning model for mental healthcare. Further, The Banyan has engaged with the Panchayat offices to discuss issues related to mental health, such as early symptoms, clarifying misconceptions, and addressing stigmas. Currently working with about eight Panchayats in Tamil Nadu, this has proven to be a highly valuable engagement where The Banyan continues to push for mental health to be included into the public health agenda and ensure the availability of psychiatric drugs and counseling at Primary Healthcare Centres. By ensuring early detection and treatment options are made available at the community level in rural areas, fewer wandering mentally ill women will end up homeless in urban areas. 

The vertically-integrated approach of The Banyan incorporates support, vocational training, rehabilitation, and permanent care of the mentally ill has been widely recognized. A study conducted by the National Institute of Mental Health and Neurosciences, Bangalore, examining the efficiency of the Banyan model, concluded that the Banyan experience of caring for the mentally ill has proven successful with 40 percent of the patients showing improvement and returning back to society. Further, Vandana has assisted COs across three states in the replication of the Banyan model, which focus on healthcare delivery to homeless mentally ill, and aspects of their rescue and rehabilitation, into their own programs. She is also strategically partnering with other cross sector organizations to include mental health into their agenda, as in the case of her work with the Mother Teresa’s Missionaries of Charity, which works on a large-scale with the homeless and impoverished.

More recently, Vandana has set up the Banyan Academy for Leadership in Mental Health (BALM), to leverage the learnings of the Banyan and equip key stakeholders in spreading Banyan’s work. Through academically rigorous and scientifically sound studies on various issues around mental health, BALM intends to influence policy and best practices in mental health. It is also focusing on creating a cadre of mental health managers to address the gaps in human resource shortages in India. Vandana has sought to redefine the nature and scope of a social worker, and how they can engage the field of psychiatric social work. By working with psychiatrists, nurses and other medical staff, these social workers provide critical psychological support and counseling to assist the client through treatment, recovery, and aftercare support. 

For instance, BALM has partnered with University College London and the Tata Institute of Social Sciences, Mumbai, to offer professional courses with a focus on psychiatric social work and mental health specializations in its centers across six locations in India. Further, Vandana has connected with the Central Government’s District Mental Health Programme to ensure that these social workers are placed in rural centers for an initial period of three years, to ensure her proposed model works on the ground. Efforts are also being made to introduce mental health management into mainstream business administration programs to increase the quality of health management in India. 

Additionally, in her capacity as the advisor to the Commissioner appointed by the Supreme Court on Homelessness for the state of Tamil Nadu and as Member of the National Level Policy Group on Mental Health, Vandana is engaging with the government to change existing policies around mental health, increasing budgetary allocation for mental health spending in India (successfully increasing it from Rs. 1,100 crores to Rs. 6,000 crores or US$960M), and by devising many cross-sectorial engagements in the fields of education, disability, and maternal health. One such initiative is to include mental health support into maternal care programs to deal with issues of postpartum depression, among others. She is also looking to include homelessness as a result of mental illness as a factor in determining one’s Below Poverty Line status. Thus, having designed the new architecture for the most challenging subgroup in in the field of mental health, the mentally ill homeless, Vandana is at the forefront of a movement to redefine and restructure the mental health space in India.




THE PERSON

Vandana has been deeply influenced by her mother who never tolerated injustice and spoke out against it. Her father was an officer with the Indian Air Force so Vandana moved countless times and as a result, and attended different schools in India. As class monitor in high school, she had the opportunity to give her first speech, which she chose to give on the then Prime Minister of India, Indira Gandhi. This made a huge personal impact on her and she recalls becoming “aspirational” from that point on. This experience made her accountable for what she said, and she began to think about the ideas of freedom, equity, and what a better world should look like. 

Vandana returned to her hometown of Chennai around the age of 15 and became exposed to a world outside the armed forces community. She was deeply disturbed by what she saw. Despite suffering from emotional highs and lows, she was given no counseling and she realized that there weren’t enough resources for people seeking mental health support. As a student of English Literature, she began writing and went from being depressed to starting to feel a great sense of hope. Her desire to work toward a better world returned.

Some years later, as a master’s degree student specializing in psychiatric social work in Chennai, Vandana had the opportunity to visit the Institute for Mental Health, a premier government run mental hospital in Chennai. She was appalled by what she saw, and shared her experiences with her friend and later co-founder, Vaishnavi. Together, they returned to the institute several times to further understand the situation. She visited other organizations caring for mentally ill persons and found the atmosphere stifling and one that robbed patients of their freedom.

One day, Vandana encountered a naked woman near a bus stop on a crowded street outside her college. The woman clearly appeared to be mentally disturbed and lost. Determined to do something about it, she approached the authorities at her college who helped put this woman in a large CO. Despite being well cared for. Vandana learnt that the woman had run away soon after, and had become untraceable. Frustrated with this incident, Vandana realized that the problem was much broader and the entire mental health delivery mechanism was not designed to help such people. 

Vandana and Vaishnavi designed a system of care that would seek out, treat, and reintegrate homeless mentally ill people into society. Their system would be built on the themes of dignity, empathy, empowerment, and freedom. They began by finding a house and living alongside rescued mentally ill women; learning as they went along to try to determine appropriate interventions. Living on a day to day basis with rescued women in these initial years helped Vandana understand their medical and emotional needs. This helped her discover effective ways to invoke their sense of responsibility for themselves, acquire dignity, and work toward their long lost aspirations. 

Due to a lack of similar facilities elsewhere in Chennai, Vandana’s shelter became immensely popular, and soon they had to move to a larger space to accommodate more women. Within three years, their initiatives were noticed by the Chief Minister of the state of Tamil Nadu, who granted them a few acres of land to officially set up their Transit Care Centre, aptly named Adaikalam, meaning “Refuge.”

Vandana’s work is fueled by the passionate belief that everyone should have the freedom and opportunity to strive for a better life. Vandana strongly believes that mental illness is a part of the human experience but should not define us. 




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