I’ve been settled in Mysore now for two weeks.  I decided to post this a little early (I’m more or less scheduled for alternate Tuesdays) because I’ve been getting questions from people about what exactly I am doing here!  The project I am working on with Karuna Trust is writing a standard operating procedures manual for Manasa, their short-term sheltered accommodation facility for mentally ill homeless women, rather poetically called the “wandering mentally ill” here.  The intended purpose of the manual is to provide comprehensive written information on Manasa to Karuna Trust staff and possibly also to other NGOs in India that may want to try and replicate this model of mental health care in other states. The work the Trust is doing in this area is much-needed and fairly ground-breaking here.  They began operating Manasa out of a rented facility in 2006 after deciding this would be an area of focus for them given the gap in care they had observed for this population of very marginalized women.  They were then able to acquire a piece of land (slightly outside of the city but still within easy reach by public transportation) and construct a new building (funded entirely by donations) which opened a year ago (see photo).  The building has been designed well given it’s purpose.  It is a rectangle with the rooms arranged around the perimeter and the inside cut out for a courtyard garden. This creates a covered walkway with access to rooms on one side and the courtyard on the other.  The entire facility would likely be regarded as small by American standards but its simple, smart design and the newness of the building create a good impression — clean, airy, bright, and pleasantly basic.  Even the work spaces for staff are not cluttered with computers, office furniture and filing cabinets as they would be in the U.S. They are sparely furnished and open. Another difference is that the residents wander in and out of the staff spaces regularly. There is no sense that there are spaces that are off limits to them, although they are shooed away if there are meetings going on.  The facility currently houses 50 women but could hold a maximum of 75. On average there are 60 women at Manasa at any one time.

The objectives of Manasa are to “rescue, rehabilitate, and reintegrate” mentally ill homeless women.  A woman is brought to Manasa after a psychiatrist has evaluated her and made a diagnosis and after she has had a routine health screening at a local hospital.  Typically this process is precipitated by a call to Manasa either by the police or by a concerned citizen. Once at Manasa, the woman is then started on a course of medical treatment to stabilize her condition. The most common diagnoses are bipolar affective disorder, schizophrenia, and psychosis (unspecified).  While the medications are started she is housed, fed, counseled, and encouraged to participate in chores and occupational therapy activities.  Her physical health needs are also attended to.  A psychologist, social worker, and staff nurse are with the residents daily, along with live-in health care workers. A psychiatrist and physician visit several times per week to consult with the staff and to see the patients to evaluate their response to medications and make adjustments to dosages as needed.  During this time a history of the woman is also taken and the staff acquire the names and addresses of family members from the women themselves, assuming they are able or willing to provide them.  Karuna Trust contacts the families to alert them to the whereabouts of their wife or daughter or sister and begins developing a “reintegration” plan.  The goal is to stabilize the women, return them to their families and communities, and then turn over care to the local primary health center (PHC) in the woman’s community.  (This is consistent with another Karuna Trust priority: integrating mental health care into primary health centers.)  Even when a woman has returned to her family, Karuna Trust will continue to provide her medications for free for her lifetime.  Once reintegrated, the woman is expected to meet regularly with her PHC doctor to maintain care and compliance with medications.  While reintegration is not always possible, it remains the primary goal.  Alternative resources are made available to women whose families cannot be located.

When I traveled here for the internship I had expected to be working on an entirely different project. However, I am finding this to be a fascinating experience nonetheless.  I find it especially interesting bumping up against cultural differences so profound that I cannot even find a way to ask a question in a way that is understandable to my listener. I ask, and they answer a different question or do not answer at all out of sheer puzzlement. For example, I have asked many times questions around a woman’s autonomy — What if she does not want to come to Manasa? What if she wants to leave soon after arriving? Can she discharge herself if she came voluntarily?  The question is clearly seen as almost nonsensical.  Why would a woman refuse?  And why would anyone even listen to a woman with a diagnosed mental illness?  I do understand there is a fine line in these situations because releasing a destitute woman back onto the streets to wander must seem the ultimate in cruelty. On the other hand, with no family members initially to advocate for them and no real say in their medication regimen, without even necessarily having been brought to Manasa voluntarily, the women really are confined there for months, perhaps against their wishes.  This troubles me although I have no solution to offer under these circumstances. Probably the most that can be hoped for is a systematic, careful, compassionate effort to explain to the women (in terms they can best understand) during the intake/admission process what is happening and what to expect from their stay at Manasa.

Another cultural difference, but one which became immediately apparent to both sides, was my question, “What if the family will not take her back?”  “What if they do not want her?”  To me, given my cultural background, this seemed like a problem that might occasionally arise.  I could see in America a family perhaps not wanting their schizophrenic grandmother back in the house, instead being quite happy that she was being cared for elsewhere, especially for free.  But my listener only laughed at this question.  It simply does not happen here.  Indian families are always happy to have their daughters and wives back.  It is never an issue. 

Clare Leinweber
Karuna Trust – Mysore