Gender and Mental Health Combining Theory and Practice

Gender and Mental Health

Meenu Anand Editor

1 3


Meenu Anand
Department of Social Work University of Delhi
New Delhi, Delhi, India

ISBN 978-981-15-5392-9

ISBN 978-981-15-5393-6


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This book is dedicated to my father and my late mother who gave me the best and the happiest childhood.


The subject of gender has always intrigued me, as a woman and as a feminist scholar. Over the years, during the course of my research and teaching, I developed a passion for exploring gender, its many contours and subthemes. As my life evolved through varied phases, those of happiness and elation, challenges and turmoil, I steadily began to question the very notion of normality, often deeply embedded within the realm of mental health, in academic discourses as well as in societal practices.

The inception of this book stemmed from a strong desire to put together an integration of schemas on mental health from an eclectic standpoint. Being a social work educator and a scholar of gender studies, I strongly believe in praxis between theory and practice. Hence, no effort of theorizing a concept can be complete (for me), without the amalgamation of field-based narratives. This book is a humble attempt to bring together the models and approaches on mental health by social work professionals, medical practitioners and academicians along with voices and chronicles from significant grass-roots practitioners/projects.

I would like to thank a number of people who have been instrumental in both the genesis and production of this book. I would like to begin by thanking Prof. Werner Menski who put me in contact with Ms. Satvinder Kaur at Springer Nature. Without this first milestone, this volume would surely not have been possible. I also thank Prof. Archana Dassi for her eternal inspiration and faith in me that continues to inspire me to undertake all my professional assignments with perfection. I humbly thank Dr. Malathi Adusumalli and Prof. Nilima Srivastava for assiduously bearing with my never-ending cathartic narrations about the progress of manuscript. I sincerely thank Prof. Malashri Lal who has always encouraged me to aspire for ‘quality writing and publications’ in order to experience the true joy of taking one’s work forward. I also would like to express my humble gratitude to Ms. Satvinder Kaur at Springer Nature for her belief and confidence in my work, unequivocal warmth as well as professionalism demonstrated by her with utmost conviction and cooperation. With great humility, I would also like to sincerely thank each and every contributor of this book who trusted me immensely with this


viii Acknowledgements

colossal task, sharing their unique experiences and phenomenal works, despite many of them having never met me. A special thanks to Prof. R. Srinivasa Murthy and Dr. Bhargavi V. Davar for having created a voluminous body of scholarly work in the area of mental health with so much passion and commitment which indeed has been a great source of encouragement and motivation for me.

On a more personal note, I am forever thankful to my son Tanish, who has been my constant companion and a witness to my arduous journey of managing various professional and personal responsibilities. He has been my sole companion throughout the years while I burnt the midnight oil during the course of this journey, especially after having gruelling days at the university. I also wish to thank my husband Jitender for partnering and bearing with me, my mood swings, and providing unconditional and steadfast support like a loyal friend. My preoccupa- tions certainly affected our quality time together, but he always staunchly loved me and respected my need to create my own space and carve my niche.

I am equally indebted to Indu Bhabhi and Preet for cheering me and loving me tenderly whenever I was battling through bouts of loneliness. It was due to our awesome and ‘foursome’ camaraderie (along with Tanish) that I sailed through difficult phases by laughing out aloud amidst relishing splendid delicacies.

I would also like to thank Gunjan who helped me with technical assistance and all those who provided me immense moral strength. I may have mentioned only a few names, and there have been many more persons who have impacted me, blessed me and helped me inaudibly during the course of this journey.

Last but not least, I pray and hope to do justice to all my contributors and the potential readers of this book by presenting a volume which is compatible to suit the unique learning requirements of students, research scholars, academicians as well as field practitioners and enable them in their diverse works.

29th June 2020 Meenu Anand


Mental health is gendered. The association between gender and mental health therefore has become an intersecting and prominent topic not only within the domain of sociology but also in the fields of psychology, social work, epidemiol- ogy, psychiatry and public health (Chien-Juh Gu 2006). The discourse on gender and mental health has become an integral part of the contemporary debates. According to WHO, gender refers to the range of socially constructed roles and characteristics of women and men, and sex refers to biological differences (WHO 2011; Muehlenhard and Peterson 2011).

Gender and mental health have emerged as an important traversing treatise in relation to the contemporary sociocultural ethos in Indian society, its dynamics of power and politics. As a critical determinant of mental health, gender has received significant attention with respect to promotion and protection of mental health and fostering resilience to stress and adversity. Understood as varying sets or relations, norms and identities related to ideas of what constitute femininity and masculinity or transgendered identities, respectively, gender determines the differential power and control gendered individuals have over the socio-economic determinants of their mental health and lives, their social position, status and treatment in society and their susceptibility and exposure to specific mental health risks. A gendered approach to mental health implies distinguishing between biological and social factors while exploring their interactions and being sensitive to how gender inequality affects health outcomes.

Few would disagree that sex is of relevance in understanding and treating mental disorders, but there seems to be less consensus on the extent to which researchers should consider sex and gender in study design, analysis and interpretation. The Institute of Medicine defines sex as ‘the classification of living things, generally as male or female according to their reproductive organs and functions assigned by chromosomal complement’ (Wizemann and Pardue 2001). Gender is defined as ‘a person’s self-representation as male or female, or how that person is responded to by social institutions based on the individual’s gender presentation. Gender is shaped by environment and experience’. These definitions have been criticized, particularly for treating sex and gender as dichotomous variables (whereas many


x Introduction

of the sex-related and gender-related differences in function and disease are more usefully conceptualized as continuous variables) and focusing on the individual (which neglects the multidimensional relational nature of gender). Differences in the epidemiology of mental disorders in men and women are well established and are often conceptualized as being due to sex (i.e. biological) differences; the increased risk of psychosis in the post-partum period is a classic example. Sex differences in both response and adverse reactions to psychotropic medication have been identified (Howard et al. 2017).

The Notion of Normality

I also wish to dwell upon the very notion of normality which in itself is a very complex as well as a contested term in the field of mental health. In fact, the concept of mental health seems to be a more complex concept than mental illness. Zachrisson (2019) questions ‘what do we mean by mental health, and what is the relation between mental health and normality?’

The medical definition of health has been the ‘absence of illness’. It has been criticized as too narrow and too somatic. In 1948, the World Health Organization (WHO) gave an alternative definition of health: a state of perfect somatic, mental and social well-being, not only the absence of illness or handicaps. The objections have been that this conception is difficult to delimit and that it denotes an unattainable ideal, not a normal state. The sociocultural notions of health denote the significant cultural variations as well as subjective understandings of the term. However, most judges agree that mental health and mental illness are not mutually exclusive. That implies that the mere absence of mental illness does not necessarily mean good or sound mental health. One way to conceptualize mental health may be to see how a person handles his/her everyday life. Thus, operationalizing the very concept of mental health is in itself a challenge. As Zachrisson (2019) argues

Who of us has not felt anxiety or a hint of panic; who has not asked himself: did I lock the door and turn off the stove before I left home? Who has not had moments of confusion and loss of sense of reality or of identity feeling? Such moments are not signs of mental illness. They become illness, if they take on a dominating place in mental life. When the thoughts of the stove or the door does not leave us, but become obsessions or compulsions. Who has not felt insecure and wished to withdraw from an exciting challenge; or, the other way around, submitted to a wish to stand in the centre of peoples’ attention, without having a contribution to give? We talk of illness only when these reactions take on a dominating role, and call it narcissism—a state that in moderate form is universal (p. 2).

Jaramillo and Restrepo-Ochoa (2015) reiterate the notion of normality often understood as a criterion of demarcation between what is considered ‘healthy’ or ‘sick’, ‘adapted’ or ‘maladjusted’, and ‘welfare’ or ‘discomfort’ as a problematic situation. According to them, the notion of normality is multivalent and relative, product of the socio-historical context in which it is conceptualized, and is anchored in the interests of different groups of power (scientific, political and economic).

Introduction xi

The normality and abnormality debate, largely governed by the diagnostic criteria of ICD and DSM, tends to create compartmentalizations and hierarchies within the human society. The origin of the ‘other’ creates categories where people who do not fit in can be placed away from the mainstream. This may lead to prejudice and discrimination and the physical separation of people to the margins of that society. Sibley (1995) traces the physical marginalization of people in what he calls the ‘geographies of exclusion’. Part of the process of exclusion is where the ‘bad’, the ‘mad’ and the ‘imperfect’ are deemed to be ‘other’ and, often in stereotyped form, are disregarded or rejected. Being the ‘other’ in mental health terms means being on the ‘them’ side of the normality/abnormality boundary. What does it mean to be regarded as abnormal? Indeed, what is the nature of mental distress? What does it mean to have mental health problems? It all depends on where the boundaries are drawn and by whom. A boundary may often be drawn, for example, in a way that differentiates mental distress from ideas of what constitutes mental health and well-being. A person experiencing mental distress is, therefore, at least temporarily on the other side of the divide from those who are ‘normal’ or ‘sane’. Boundaries divide and define, but do they help to explain (Open Learn University 2016)?

To set the tone correct, if ‘mental disorder’ means any disability or disorder of mind, this implies that there is some sort of mental ‘order’, an internal state where there are calm and coherence. The boundary between mental health and mental disorder is therefore concerned with the controversial idea of normality and what society regards as normal (Coppock and Hopton 2000). Keyes (2002) has described the mentally healthy as ‘flourishing’ and also introduced a new concept—‘lan- guishing’. We often indulge in the importance of flourishing and pay attention to the problems associated with languishing, debate about what ‘flourishing’ and ‘lan- guishing’ entail. However, I always wonder about the very two ends of the dual continuum model. I often find my own self, and so many others, constantly jostling and moving along the dual continuum, back and forth, stopping and (re)starting as our lives change turns, flourishing sometimes and also languishing at others. I myself have found myself struggling and hanging ‘in between’ many a time in my life. I feel that a more inclusive way of thinking about mental distress would be to avoid the fixed boundary between ‘them’ and ‘us’, and allowing everyone to move between points as circumstances change and episodes of distress come and go. Furthermore, I strongly feel that the normal–disordered discrimination needs to be challenged today as we are constantly dabbling with the upcoming thrusts on community mental health or rehabilitation of persons from a strength-based per- spective. However, the reality is a far cry from these. The gender-based differentials create double whammy for women which implies hegemonic boundaries and fur- ther subjugation. Women with mental illness therefore are not only subjected to discrimination owing to them being ‘the inferior sex’ but also because they are the ‘other’ on the continuum of normality–abnormality.

xii Introduction

Gender Differentials in Mental Illness

The boundaries between the other and the rest become more distinct when it comes to a gendered analysis. Women are exposed to a wide range of specific risk factors that can increase their risk of poor mental health (Astbury 2001; WHO 2012). Men and women experience different varieties of mental health problems. According to WHO, depression, anxiety and somatic complaints are more common for women. Unipolar depression, predicted to be the second leading cause of global disability burden by 2020 (Murray and Lopez 1996), is twice as common in women. Women are about twice as likely as men to develop depression during their lifetime (WHO 2013; Geo et al. 2019; Weissman and Olfson 1995; Desai and Jann 1999; Aneshensel 1992; Caldwell et al. 1987; Dohrenwend and Dohrenwend 1974; Gove 1972, 1987; Mirowsky and Ross 1986; Rosenfield 1989). Women also predominate in the disability associated with mental illness which falls most heavily on those who experience three or more co-morbid disorders. In contrast, while women exceed men in internalizing disorders such as depression and anxiety, men exhibit more externalizing disorders such as substance abuse and antisocial behaviour, which indeed become problematic for others. Research on gender and mental health suggests that conceptions of masculinity and femininity affect major risk factors for internalizing and externalizing problems, including the stressors men and women are exposed to, the coping strategies they use, the social relationships they engage in, and the personal resources and vulnerabilities they develop (Rosenfield 2012).

Feminism has consistently rejected traditional causal explanations of women’s disorder derived from allegedly natural biological predispositions, pointing instead to the effects of women’s oppressive socialization and to the consequences of devaluing women’s characteristics and abilities (Bluhm 2011). Similarly, it has emphasized the embodiment, and relationality, of the self (Bluhm et al. 2012). Furthermore, much of it influenced by social theory and phenomenological approaches focuses on the intersection of gender with marginality, invisibility, non-normativity and oppression in lived experience (Nissim-Sabat 2013; Zeiler and Folkmarson Käll 2014 as cited in Stanford Encyclopaedia of Philosophy (2019)).

At the home front, the National Mental Health Survey of India by NIMHANS (2016) too echoes the prevalence of significant gender differentials with regard to different mental disorders. The overall prevalence of mental morbidity has been found to be higher among males (13.9%) than among females (7.5%). While there is a male predominance in alcohol use disorders (9.1% vs. 0.5%) and in bipolar affective disorder (BPAD) (0.6% vs. 0.4%), specific mental disorders like mood disorders, neurotic disorders, phobic anxiety disorders, agoraphobia, generalized anxiety disorders and obsessive compulsive disorders were higher in females. Furthermore, it is significant to add that neurosis and stress-related disorders (that affected 3.5% of the population) were reported to be nearly twice higher among females as compared to males.

Introduction xiii

Kuehner (2016) summarizes evidence regarding the epidemiology on gender differences in prevalence, incidence and course of depression, and factors possibly explaining the gender gap. Gender-related subtypes of depression are suggested to exist, of which the developmental subtype has the strongest potential to contribute to the gender gap (Kuehner 2016). Sophie and Graham (2017) present the evidence from a variety of fields that suggests that sex hormones, particularly oestradiol and progesterone, play a significant part in generation of these sex differences. They report on the effects of sex hormones on biological, behavioural and cognitive pathways, to propose broad mechanisms by which oestradiol and progesterone influence sex differences in anxiety disorders.

Research by Rosenfield and Mouzon (2013) on gender and mental health sug- gests that gender conceptions and practices push males and females to different forms of psychopathology by increasing multiple risk factors for internalizing and externalizing problems. The amount of these risk factors makes gender differences seem socially overdetermined—that is, resulting from more causes than are nec- essary to produce the outcome. Men and women in different races and classes are predisposed to varying problems through the stressors they experience, the coping strategies they use, the social relationships they engage in, and the personal resources and vulnerabilities they possess. These differences also seem overdeter- mined insofar as the conceptions of gender underlying these risk factors are con- veyed through socialization and major social institutions including schools, families and workplaces.

Sociocultural Determinants

The impact of sociocultural determinants in gender-specific mental health has been a significant research topic. Not only are women exposed to a wide range of specific risk factors making them more vulnerable to mental illness, but they are also at higher risk of developing co-morbidities when these risk factors occur together (Patel 2005). Gender norms, understood as the sets of rules for what is appropriate masculine and feminine behaviour in a given cultural context, play a predominant role with respect to a sociocultural understanding with respect to gender and mental health. Since gender norms make up a sex role, a set of expectations about how someone labelled a man or someone labelled a woman should behave; feminization and masculinization take place through overt and covert means during the course of socialization, thereby becoming an internalized part of the way one engrains one’s gender identity (Anand 2019; Ryle 2015).

Davar (1999) examines research on women’s mental health and synthesizes a bio-psychosocial model takes into account complex contextual factors, especially psychosocial causes. The socially constructed differences between women and men in roles and responsibilities, status and power interact with biological differences to contribute to differences in mental health problems experienced, help-seeking behaviour and the responses of the health sector (Babacan 2014).

xiv Introduction

A strong inverse relationship exists between social position and physical and mental health outcomes. The key gender influences for women include women unduly bearing the burden of poverty, and this influences their likelihood of suf- fering depression; women are much more likely than men to experience violence, particularly sexual abuse and partner violence; women are more likely to work in jobs that are unstable and of low status, and carry the burden of carrying, partic- ularly unpaid role of carer (Babaca 2014, pp. 235). The prevalence of co-morbidity increases the severity of mental illness and increased disability (Astbury 2001). Hill and Needham (2013) examine three propositions that are widely (but not univer- sally) accepted in the gender and mental health literature. First, women and men have similar or equal rates of overall psychopathology. Second, affective disorders like anxiety and depression, which are more common among women, and beha- vioural disorders like substance abuse and antisocial personality, which are more common among men, are functionally equivalent indicators of misery. Finally, women are more likely to respond to stressful conditions with affective disorders, while men are more likely to respond to stressful conditions with behavioural disorders. However, their propositions received little empirical support.

Ogundare (2019) highlights the role of culture in the conceptualization of mental illness and the phenomenology of mental illness across cultures. Conceptions of gender and gendered practices generally include the division of labour, the power differences between men and women, and the character traits associated with males and females. Though the scenario has been changing, men still primarily retain the primary responsibility for the economic support of the family, and women are still responsible for caretaking and domestic work, regardless of whether they are employed (Rosenfield and Smith 2009). The dominant societal form of femininity —which Connell calls emphasized femininity—stresses personal traits of submis- siveness, nurturance and emotional sensitivity as ideals (Connell 1995). In contrast, dominant conceptions of masculinity—termed hegemonic masculinity—associate men with assertiveness, competitiveness and independence, traits needed for suc- cess in the labour market (Connell 1995; De Coster and Heimer 2006; Hagan 1991; Heimer 1995; Heimer and De Coster 1999; Schippers 2007; Simon 2002).

Women are nearly twice as likely as men to suffer from mental illness, while men suffered from more mental health problems than women when dealing with situations of high wealth inequality (Shoukai 2018). Rosenfield and Mouzon (2013) further argue that women face more recent life events than men, and consistent with their greater responsibilities for caretaking and maintaining social ties, they suffer from more stressors involving significant others such as family events and the death of friends or relatives. In contrast to women, men endure more traumatic or adverse events over the course of their lives, e.g. indulgence in violence, substance abuse, etc. Combining these studies, women’s excess of internalizing problems partly results from the time pressure of household tasks and the overload of job and family demands. These patterns are consistent with role theory, which postulates that men’s and women’s mental health problems are derived from destructive aspects of their gender roles (Meyer et al. 2008).

Introduction xv

The significance of sociocultural differentials is reiterated by American Psychiatric Association (2017) that identifies disparities between women and men in regard to risk, prevalence, presentation, course and treatment of mental disorders on three accounts. First, it delineates that women disproportionately experience various risk factors for common mental disorders than men. These include violence, less earnings, poverty and role as caregivers among women as compared to men. Second, APA points out the gendered differences in seeking/receiving mental health services that include women being prescribed psychotropic drugs, seeking help from medical practitioner rather than a specialist and likelihood of being diagnosed for depression by their physicians. Third, APA lists various economic barriers, lack of awareness about mental health issues, treatment options, available services, prevalence of stigma associated with mental illness in addition to the lack of time/related support and lack of appropriate intervention strategies as key barriers to mental health treatment for women.

Rosenfield and Mouzon (2013) further argue that women suffer more than men from internalizing disorders, which turn problematic feelings against the self in depression and anxiety. This difference means that women endure attributions of self-blame and self-reproach more often than men. Women struggle with a greater sense of loss, hopelessness and feelings of helplessness to improve their conditions. They also live with more fears in the forms of phobias, panic attacks and free-floating anxiety states. In contrast, men predominate in externalizing disorders and more likely to have enduring personality traits that are aggressive and antisocial in character, with related problems in forming close, enduring relationships.

Gender differentials in coping mechanisms are highlighted by Ashfield (2014) who found that:

Women tend to ruminate and are verbally emotionally expressive; they employ a rumi- native and expressive style of coping—consistent with their sex-specific biology, cultural conditioning, and the kind of roles they perform. Men tend to suppress, are less concerned with relationships, and are generally verbal and emotional economists; they employ a more suppressive instrumental style of coping, which is likewise consistent with their sex-specific biology, cultural conditioning, and the roles they must perform. (p. 223) (as cited by Francis and Elias, 2017, p. 147).

The subject of gender differentials becomes even more relevant in the Indian mental health scenario where gross violation of women’s human rights takes place. There is a need for the state to take multipronged steps to reduce gender discrimination, act on the risk factors and promote the protective factors for enabling mental health and well-being with thrust on girls and women. There is a need for in-depth research and relevant literature in the field of gender and mental health that is backed by lessons and evidence from the field.

xvi Introduction

What This Book Offers?

This book brings together a range of scholarly as well as experiential reflections on the subject of gender and mental health. It aims to draw attention to the urgent need for amalgamation of academic as well as grass-roots realities on the theme. It seeks to explore and document the inclusion of practice-based interventions, which is actually the ‘need of the hour’. It summarizes the complex intertwining of illness and culture and attempts to combine theoretical discourses along with the success stories as well as challenges from the field.

This book is divided into three parts. Part I ‘Conceptual Underpinnings for Gender and Mental Health’ brings together a theoretical understanding on gender and mental health and lays a backdrop to understand the intricacies surrounding the theme. It entails the background and multifaceted theoretical frameworks for gender and mental health. Nilima Srivastava and myself present the Introductory Framework to discuss why gender matters in mental health and explain the rela- tionship between gender and health-seeking behaviours. Our chapter “Understanding Gender and Mental Health” attempts to present the diverse approaches related to mental health while thrusting on the significant sociocultural determinants including differential socialization as well as mental illness among women and men. The chapter seeks to interlink the issues of mental health with an attempt to probe a deeper understanding of micro-level issues within the overall context of the perpetuating nature of inequities from a gender lens.

Bhargavi V. Davar in her chapter “Gender, Depression and Emotion: Arguing for a De-colonized Psychology” examines the colonial assumptions about women, their expressed emotions and ‘disorders’ of the emotions. She questions from the gender/culture perspective the colonial assumptions that (i) emotion is (located) within the individual and (ii) emotion is mental. She argues for the social and the embodied aspects of emotions reiterating that emotion is in the body and is expressed through the body. She also thrusts that emotion is always in relation to the other and often constructed with the other. Examining a few folk stories, and historically revered myths, including the Neeli myth from south India; the Kannagi story; and the story of Rudali, Davar illustrates how women’s emotions are embodied expressions of distress. She further claims that their object reference is to the other, often within contexts of patriarchal silencing and an extant milieu of violence.

Saswati Chakraborti in her chapter “Women with Mental Illness: A Psychosocial Perspective” builds upon the gendered understanding of mental illness and argues how women’s mental health is intrinsically linked with the larger multifaceted social, political and economic issues prevalent across the sociocultural milieu. Citing several factors affecting mental and emotional well-being of women, she presents field-based evidence to claim how women face the gender disadvantage and are more predisposed to mental illness as against their male counterparts.

The prevalence rates for psychological disorders are examined by M. S. Bhatia and Aparna Goyal in “Gender Roles in Mental Health: A Stigmatized Perspective”.

Introduction xvii

They base their arguments on the bio-psychosocial model of health and present a gender perspective on mental illnesses including premenstrual dysphoric disorder, post-partum psychiatric disorders, perimenopausal and menopausal disorders. As medical practitioners, they also examine the role of oestrogen in mental health while presenting the key gender-specific risk factors from a psychosocial lens and make significant recommendations towards prevention of mental disorders among women.

Cross-cultural perspective and its relevance in the realm of mental health are highlighted by Malathi Adusumalli in “Understanding and Locating Mental Health in a Cross-Cultural Context: Indigenous Community Perspectives”. She explores with reference to ideas related to health and well-being from two indigenous communities—Chenchus and Jad Bhotiyas from two states, Telangana and Uttarakhand, respectively. She traverses the various articulations on health and illness, through the various ‘acts’, which are culture-bound and highlight how the ‘natural context’ is quite closely enmeshed with the belief systems and the ‘per- formative acts’ for health and well-being, which are gendered. She highlights the need to understand the varied notions of mental health, going beyond the notions of ‘defined categories’, including even the concept of mental health.

Part II of this book ‘Mental Health Scenario in India: A Gendered Lens’ seeks to examine the contemporary scenario of mental health in the country from a gender perspective. The first paper in this part is by R. Srinivasa Murthy who divulges into the “Mental Health Aspects of the ‘#MeToo Movement’: Challenges and Opportunities”. Citing recent evidences of atrocities on women and gender dis- crimination prevalent in society at large, he addresses various aspects of the mental health including the recognition of the gender inequalities as vital to bring about changes, integration of mental health knowledge in recognition of the importance of equality, social connectedness, the lifelong impact of adversities like child trauma, living in conflict situations, value of family life and impact of urbanization. He also presents the importance of understanding the mental health impact of changes at the level of individuals, families, community, state, international levels as part of the change process and the need for systematic engagement of the society at many levels, to prevent or protect women against similar situations.

Significant interlinkage among the diverse yet interconnected themes of “The Intersectionality of Gender, Disability and Mental Health” is examined by Abhishek Thakur. Demonstrating a link between emotional challenges and psy- chological struggles involved in living with impairments, he presents how various psychosocial challenges may create risk factors as well as vulnerabilities, all of which can contribute to experiences of mental distress for disabled women in their lives.

Taking the idea forward, the next chapter is by two medical practitioners, Smita N. Deshpande and Ananya Mahapatra, who review the role of gender in influencing the onset, clinical symptoms, course and outcome of schizophrenia. They examine the gender standpoint in the social consequences of the illness in terms of the degree of disability, quality of life, stigma, discrimination and social outcomes. Recognizing the eclectic approach in treatment and rehabilitation, they

xviii Introduction

too make recommendations and also signify the role of social workers in facilitating gender- and culture-sensitive interventions to improve treatment outcome in both male and female persons with schizophrenia.

Vibhuti Patel in her chapter “Urban Women and Mental Health Concerns in India” deliberates on the worsening socio-economic and political situation in India that has enhanced the rates of common mental disorders and minor psychiatric morbidity. She also presents mental issues of adolescent girls, substance abusers, HIV/AIDS-affected persons and among women in the reproductive age group, post-menopausal women, women in mental health institutions, etc. Patel also suggests holistic strategies involving the civil society and the state to provide greater opportunities to women across all age groups for self-actualization to enable them to attain high levels of mental health.

Last but indeed the most significant part of the section is the legal standpoint with respect to the gendered aspects of mental health as explored by Saumya Uma in “Female Criminality, Mental Health & the Law”. Uma dwells with a particular focus on female criminality and criminal law’s treatment of women accused of heinous offences. Her chapter undertakes the analysis primarily through a critical examination of judgements delivered by the High Courts and the Supreme Court of India in addition to laying out and analysing the contours of law and state responsibility vis-à-vis women’s mental health. Drawing upon a combination of medical research, theories and analysis in the field of psychology and jurisprudence around the world, analysed through a feminist perspective, she critiques recent judgements of the higher judiciary in India on both the issues. While the attempt of Indian courts to infuse a gender perspective into the criminal law defences is a positive step, the paper advocates caution, to avoid gender stereotyping of accused women, and calls for a more active conversation between relevant actors in the fields of criminal law, mental health, forensic sciences and gender studies.

The third and final part ‘Gendering Mental Health: Field Narratives’ echoes voices from the field, as the most critical element for making feminist interventions in the field of mental health. It focuses on presenting and embodying narration of field experiences, the success stories as well as the challenges with thrust on praxis between theoretical understandings and grass-roots realities. The first paper in this part is by Roy Abraham Kallivayalil and Sheena Varughese as they set the tone through unveiling the concept of psychosocial rehabilitation (PSR). Kallivayalil and Varughese in their chapter “Psychosocial Rehabilitation—The Past, Current Approaches and Future Perspectives” as an essential component of management of persons with chronic mental illness along with pharmacological management. They argue about the twofold goals of psychiatric rehabilitation to help disabled indi- viduals to develop the emotional, social and intellectual skills needed to live, learn and work in the community and develop environmental resources to reduce potential stressors. They cite their Kerala experience as a model suitable for low- and middle-income (LAMI) countries to develop innovate strategies to meet the challenges of mental illness.

No piece on the success of interventions in the field of mental health can be complete without the mention of The Banyan, one of the most prominent

Introduction xix

organizations working in the field of mental health in India. Lakshmi Narasimhan, K. V. Kishore Kumar, Barbara Regeer and Vandana Gopikumar in their chapter “Homelessness and Women Living with Mental Health Issues: Lessons from the Banyan’s Experience in Chennai, Tamil Nadu” describe their experiences in developing a continuum of care for homeless people with mental illness. Their contribution examines the Emergency Care and Recovery Centre which offers crisis intervention to reintegration services for homeless women with mental illness and also frames within the narrative of this experience, implications for mental health policy and practice for an extremely marginalized population. In particular, they dwell on the prospects for issues of long-term care and intersectoral service inte- gration between health and social welfare for the homeless population in the light of recent developments in progressive disability and mental health legislation in India.

Another enormously significant effort in India towards rehabilitation of women recovering from mental illness is narrated by Shubhada Maitra and Ashwini Survase in their chapter “Tarasha’s Experience of Working with Women Living with Mental Illness: ‘Melee tar aamchi, Jagli tar tumchi’ (‘if she dies she is ours, if she lives, she is yours’)”. Citing real-life illustrations from their field action project, Tarasha, initiated by the Centre for Health and Mental Health, School of Social Work, Tata Institute of Social Sciences, they discuss Tarasha’s experience of working with women living with mental illness. While tracing Tarasha’s concep- tualization and history, the authors outline Tarasha’s recovery and reintegration model drawing on women’s experiences who are currently ‘occupying’ mainstream living and livelihood spaces.

An interesting unification of gender, criminality and mental health is presented by Mark David Chong, Amy Forbes, Abraham P. Francis and Jamie Fellows in their chapter “Gender Differentials in the Presentation of Symptoms, Assessment, Diagnosis and Treatment of Mentally Ill Prisoners.” They explore how the gender of a prisoner influences the way in which a mentally ill inmate presents their symptoms (and seeks medical assistance), as well as how they are thereafter assessed, diagnosed and treated by prison health services. They also hope that penal administrators and correctional health professionals in India will be made more aware of, or sensitive to, these variances and that the subsequent assessment, diagnosis and treatment of such prisoners will be more gender-responsive so as to maximize the prospect of successful rehabilitation.

Experiential learnings from the grass roots are also presented by Anupama V. Prabhu, Anu Sonia Vincent, Uma Parameswaran and Chitra Venkateswaran from the Mehac Foundation. “Gender and Community Mental Health: Experiences of Mehac Foundation—A Community-Based Mental Health Service in Kerala, South India” outlines the experiences by the authors in dealing with mental health and illness, indicating some important developments and components of the model, with a special focus on gender. Sharing the community-based services run by Mehac Foundation, the authors focus on the importance of empowering families and providing continuous support to them enable home-based care.

Last but not least, Gunjan Chandhok and myself thrust upon the importance of strength-based approach for addressing the vital concerns related to domestic

xx Introduction

violence in our paper “Practising Strength-Based Approach with Women Survivors of Domestic Violence”. We affirm that self-determination, self-esteem and hope among the survivors of domestic violence can be inculcated and visualized as the potential key to address the imperative mental health issues. Our chapter also suggests gender-sensitive interventions in congruence with the human rights approach.

This book is unique in what it hopes to achieve: a gestalt in its unique con- solidation of theoretical underpinnings on mental health from a gender lens backed by voices from the field. It is intended as a critical confederacy of theoretical base on gender and mental health depicting the contemporary scenario as well as experiential insights from the field. It will be useful to students from a number of disciplinary backgrounds interested in either gender and/or mental health—students of social work, sociology, social policy, women/gender studies, social psychiatry and psychology. It will also be suitable as reference material for professionals who encounter women and men with mental health challenges—social workers, nurses, doctors, psychologists, lawyers, etc. I also hope that this book will be useful to anyone who is battling with the personal experience of having a mental disorder or having a member of their family with one. I strongly feel that this book will be useful for postgraduate students, research scholars as well as faculty in the field of gender studies, mental health as well as social work and sociology.

Meenu Anand


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Part I Conceptual Underpinnings for Gender and Mental Health

. 1  UnderstandingGenderandMentalHealth………………. 3
Nilima Srivastava and Meenu Anand

. 2  Gender, Depression and Emotion: Arguing for a De-colonized Psychology ……………………………………. 19 Bhargavi V. Davar

. 3  Women with Mental Illness: A Psychosocial Perspective . . . . . . .. 33 Saswati Chakraborti

. 4  Gender Roles in Mental Health: A Stigmatized Perspective . . . . .. 47 M. S. Bhatia and Aparna Goyal

. 5  Understanding and Locating Mental Health in a Cross-Cultural Context:IndigenousCommunityPerspectives ……………. 63 Malathi Adusumalli

Part II Mental Health Scenario in India: A Gendered Lens

. 6  Mental Health Aspects of the ‘#MeToo Movement’: Challenges andOpportunities……………………………….. 79 R. Srinivasa Murthy

. 7  The Intersectionality of Gender, Disability and Mental Health . . . . 97 Abhishek Thakur

. 8  Gender and Schizophrenia: Are Differences Biological orSocial?…………………………………….. 109 Ananya Mahapatra and Smita N. Deshpande

. 9  UrbanWomenandMentalHealthConcernsinIndia ………. 129 Vibhuti Patel


xxiv Contents

10 FemaleCriminality,MentalHealth&theLaw……………. 143 Saumya Uma

Part III Gendering Mental Health: Field Narratives

. 11  Psychosocial Rehabilitation—The Past, Current Approaches andFuturePerspectives …………………………… 159 Roy Abraham Kallivayalil and Sheena Varughese

. 12  Homelessness and Women Living with Mental Health Issues:
Lessons from the Banyan’s Experience in Chennai, TamilNadu……………………………………. 173 Lakshmi Narasimhan, K. V. Kishore Kumar, Barbara Regeer,
and Vandana Gopikumar

. 13  Tarasha’s Experience of Working with Women Living
with Mental Illness: ‘Melee tar aamchi, Jagli tar tumchi’(‘if she diessheisours,ifshelives,sheisyours’)……………….. 193 Shubhada Maitra and Ashwini Survase

. 14  Gender Differentials in the Presentation of Symptoms,
Assessment, Diagnosis and Treatment of Mentally Ill Prisoners . . . 207 Mark David Chong, Amy Forbes, Abraham P. Francis,
and Jamie Fellows

. 15  Gender and Community Mental Health: Experiences of Mehac Foundation—A Community-Based Mental Health Service inKerala,SouthIndia ……………………………. 223 Anupama V. Prabhu, Anu Sonia Vincent, Uma Parameswaran,
and Chitra Venkateswaran

. 16  Practising Strength-Based Approach with Women Survivors ofDomesticViolence……………………………… 237 Gunjan Chandhok and Meenu Anand

Editor and Contributors

About the Editor

Meenu Anand, Ph.D., is an Assistant Professor at the Department of Social Work, University of Delhi, India. She has an extensive professional experience and exposure in the areas of gender, education and mental health. Formerly with the Women’s Studies & Development Centre, University of Delhi, she has also taught at Dr. Bhim Rao Ambedkar College, University of Delhi. Dr. Anand has been actively involved in working on issues related to gender, mental health and edu- cation for more than two decades. She has led various national and international projects focussing on multifaceted developmental issues during her specialized work experience with various grassroots NGOs. Dr. Meenu Anand also specializes as a trainer and conducts various capacity building and gender sensitization workshops for school, college and university teachers, journalists, police personnel, NGO functionaries and several other stakeholders. She has been instrumental in the development of curriculum at the Post Graduate level on gender for Women’s Studies and Development Centre, University of Delhi. She has an exaustive list of publications to her credit, in the form of books as well as research papers in national and international journals that seek to highlight issues related to gender, mental health and social work within interdisciplinary frameworks. Dr. Anand is passionate about working and researching on gender, education and mental health.


M. S. Bhatia, M.B.B.S.; M.D.; MNAMS, is currently the Director, Professor and Head, Department of Psychiatry, University College of Medical Sciences and Guru Teg Bahadur Hospital, Dilshad Garden. He is also the Head, Department of Psychiatry, University of Delhi. Prof. Bhatia is also the Editor of the prestigious Delhi Psychiatry Journal. He has written over 259 research papers, over 50 chapters and over 15 books in Psychiatry. Prof. Bhatia is the member of many National and


xxvi Editor and Contributors

International Organizations. He is also the member of review and editorial boards of many National and International Journals.

Saswati Chakraborti works as a Psychiatric Social Worker at the Department of Psychiatric Social Work, Institute of Human Behaviour and Allied Sciences (IHBAS), Delhi. She has fourteen years of work experience at IHBAS, involved in Clinical Service Delivery, Rehabilitation and After Care of Persons with Mental illness; Training, Consultation and Research. She has published five Papers in National and International Journals and Books.

Gunjan Chandhok is a Senior Research Scholar at the Department of Social Work, University of Delhi, pursuing her Doctoral research on ‘Influence of Intimate Partner Violence on Reproductive and Sexual Health of Women’. A topper of her batch (2016–2018), during her Masters in Philosophy in Social Work from University of Delhi, she researched on ‘Reproductive and Sexual Health Rights of Young Married Women in Urban Slum of Delhi NCR’. She has several years of grassroots experience of working in communities and organizations of repute. Her core areas of interest are Public Health and Gender Issues. In addition to Post-Graduation in Social Work, she also holds a Masters Degree in Gender and Development Studies. She has presented several papers at various National and International conferences and has prestigious publications to her credit as well.

Mark David Chong is currently a Senior Lecturer in Criminology and Criminal Justice Studies as well as the Criminology. Major Coordinator for the Bachelor of Arts programme at the College of Arts, Society and Education, James Cook University (JCU), Australia. He was also formerly the Director of Research Education for the School of Arts and Social Sciences, JCU, from 2012 to January 2015. Through God’s Grace, in 2015 (and again in 2017), he was recognised for his ‘exceptional support for students with a disability’ through the university’s Inclusive Practice Award. He graduated with a Ph.D. in Law from the University of Sydney, where he received his Law School’s Longworth Scholarship (2003), the Cooke, Cooke, Coghlan, Godfrey and Littlejohn Scholarship (2004), the Longworth Scholarship for Academic Merit (2006) and the Longworth Scholarship once again in 2007. He was appointed as a Judicial Referee by the President of the Republic of Singapore on the recommendation of the Chief Justice to the Small Claims Tribunals’ bench. However, given his deep interest in criminal justice issues, Mark subsequently taught the Singapore Police Force and the Central Narcotics Bureau at Temasek Polytechnic, Singapore, under a joint academic programme with Queensland University of Technology, Australia. Of late, Mark has begun to develop expertise in converging criminology and social work through the specialisation of criminal justice social work in India. In this regard, he has published works that pertain to human rights, mental illness and strengths-based practice.

Bhargavi V. Davar is a childhood survivor of the Indian mental asylums, being exposed to a variety of them for years in early childhood. Compelled by those early experiences, she completed her Ph.D. in 1993, from the Indian Institute of

Editor and Contributors xxvii

Technology, Mumbai on the ethical and epistemological foundations of the mental and behavioural sciences. Through her early years, she studied theories of freedom and consciousness, human physiology, psychology, buddhism, ‘anti-psychiatry’, and the philosophies of social sciences. Her research has been on gender, culture and disability studies, and making sense of modern mental health policy frames in India and Asia. The impact of colonialism on mental health systems in post colonial times, in India, is also a big area of research interest. She has published works, including (co-author) Psychoanalysis as a Human Science (Sage, 1995); Mental health of Indian women (Sage, 1999); (ed.) Mental health from a gender per- spective (Sage, 2001); Gendering mental health: Knowledges, identities, institutions (OUP, 2015). She is Director of the Bapu Trust for Research on Mind and Discourse, Pune; and Convenor for an Asia advocacy platform, called ‘Transforming Communities for Inclusion, Asia Pacific’ (TCI Asia Pacific). She is a practising Arts Based Therapist and teacher; an international certified trainer of the UNCRPD; and an organic farmer. She lives with her daughter in Pune, India.

Smita N. Deshpande, MD (AIIMS), DPM (Bombay) is a Professor of Psychiatry. She is a leading researcher in schizophrenia genetics, interventions and disability with numerous nationally and internationally funded research projects and publi- cations to her credit. She led the Department of Psychiatry at Centre of Excellence in Mental Health, ABVIMS-Dr. RML Hospital for over 14 years and now heads the National Coordinating Unit of ICMR for NMHP Projects, leads the Resource Center for Tobacco Control and heads the Central India Unit of UNESCO Bioethics Chair Haifa at the Centre of Excellence in Mental Health which she initiated and established.

Jamie Fellows is a Senior Lecturer at the Law School at James Cook University, Australia and has been there since 2009. Since then he has taught and published in areas of public law, particularly on topics regarding criminal sentencing, legal history, and war crimes. Jamie’s Ph.D. topic investigates the US Army war crimes trials of the Japanese conducted in Manila after the Pacific War. Jamie lectures and coordinates compulsory and elective subjects within the LLB degree programme across the Townsville and Cairns campuses at JCU. Jamie’s teaching is informed by proven pedagogical approaches to student learning that utilises a variety of scaf- folded and blended-learning teaching practices. For a number of years Jamie has been involved in the St. Vincent De Paul Volunteer Refugee Assistance Program in Townsville. Prior to commencing at JCU, Jamie held several positions within the private and public sectors in Japan and Australia.

Amy Forbes is Associate Professor of Communication and Journalism, and is also Associate Dean, Learning and Teaching for the College of Arts, Society and Education at James Cook University. Her research interests are in the areas of intergenerational communication, emotional and mental health issues in migrant and indigenous communities, gaming and social capital formation, and advances in digital communication and design.

xxviii Editor and Contributors

Abraham P. Francis is an Associate Professor, and currently the Head of Academic Group in Social Work and Human Services at James Cook University, Australia. He has worked with Government, Non-government and corporate sector, and has developed many international partnerships. He taught social work at the Delhi University in India and worked as a senior mental health social worker with Country Health South Australia before moving to Townsville to join James Cook University. Dr. Francis has extensively contributed to the literature on Social Work practice in mental health through his publications, convening conferences, estab- lishing research networks and by developing consortiums. His other research interests are in the field of communities, criminal justice, international social work, and gerontological social work. In 2018, Dr. Francis received the NAPSWI (National Association of Professional Association Social Workers in India) lifetime achievement for his outstanding contribution to social work Education.

Vandana Gopikumar (The Banyan, BALM and TISS) co-founded The Banyan, and The Banyan Academy of Leadership in Mental Health (BALM) and has for two and a half decades focussed on developing appropriate and comprehensive mental health services that are person centric for disadvantaged groups, especially home- less persons and those living in poverty. Dr. Gopikumar is also Professor, School of Social Work, Tata Institute of Social Sciences (TISS) and Appointee, non-official member, Central Mental Health Authority under Mental Health Care Act, 2017. She was also a member of the first Mental Health Policy Group constituted in 2012. Vandana’s research interests include exploration of lived experiences of home- lessness and mental illness, transitions in societal perceptions and conceptualisa- tions of mental ill health based on social mores, social contact and cultural legacy; Assessing outcomes and impact of care models that address concerns of persons with severe mental disorders; understanding impact of adverse life events on mental ill health and recovery; childhood trauma, suicide and self-harm; notions of human rights, subjective well-being, resilience and self-directed therapy/recovery; com- munity inclusion and exclusion etc. She is deeply interested in mentoring peer advocacy movements, particularly from low-income groups and homeless persons, seldom represented in global policy discourses.

Aparna Goyal, M.B.B.S.; DPM; DNB is a Senior Resident with the Department of Psychiatry at University College of Medical Sciences Guru Teg Bahadur Hospital, Dilshad Garden, Delhi. She is also a member of the Journal Committee, Delhi Psychiatry Journal and many national Organizations.

Roy Abraham Kallivayalil is Professor and Head, Department of Psychiatry, Pushpagiri Institute of Medical Sciences, Thiruvalla, Kerala. He is President of World Association of Social Psychiatry (Paris) and the Secretary General of the World Psychiatric Association, Geneva. He was President of the Indian Psychiatric Society and Associate Editor, Indian Journal of Psychiatry. He received ‘Best Doctor Award’ from Government of Kerala. President of India presented him the

Editor and Contributors xxix

World Federation of Mental Health (WFMH) Award for meritorious services to the cause of Mental Health in 2017. He has more than 60 publications in peer reviewed scientific Journals.

K. V. Kishore Kumar is the Director of The Banyan and BALM. Earlier, he was a Senior Psychiatrist at the National Institute of Mental Health and Neuro-Sciences (NIMHANS) Bangalore, India, for 25 years, where he headed the Community Health services in the Department of Psychiatry. He has served as an Advisor to the Indian Government in developing a Policy for ‘prevention of corporal punishment’ and providing relief centres for the homeless. Dr. Kumar has also advised the World Health Organization (WHO) on mental health services in Somalia. He is actively involved in clinical practice and community care and works with homeless persons with mental illness in Government institutions. His areas of interest include com- munity mental health services; training primary care doctors and general practi- tioners; Care of the Homeless with mental ill health; Life Skills for adolescents; Psychosocial issues of disasters; Psychosocial rehabilitation of the mentally ill in rural areas using local resources; Economics of mental health; Epidemiology of mental disorders; functioning and disablement among persons with schizophrenia. He has published research papers extensively in national and international journals.

Ananya Mahapatra, MD (AIIMS, New Delhi), is currently working as Assistant Professor at the Centre of Excellence in Mental Health, ABVIMS-Dr. RML Hospital. She is a recipient of Samuel Gershon Young Investigator Award by the International Society of Bipolar Disorders (ISBD) and Michael Hong Travel Award by Asian Society of Child & Adolescent Psychiatry and Allied Professions (ASCAPAP). Her areas of interest are social psychiatry, severe mental disorders, and child and adolescent psychiatry.

Shubhada Maitra is Professor and Dean, School of Social Work, Tata Institute of Social Sciences, Mumbai. She has an M.A. in Medical and Psychiatric Social Work, TISS, Mumbai and a Ph.D. in Social Work from Mumbai University. Her areas of interest include mental health, gender, sexuality and violence with a focus on women and children. She is the Faculty-in-Charge of two field action projects of TISS: Muskaan, the child and adolescent guidance centre of TISS and Tarasha, that works towards recovery and reintegration of women living with mental illness. She functions as an external member on committees for prevention of sexual harassment at the workplace for several large corporate organisations based in Mumbai with business all over India. She has contributed several articles to national, international journals and edited volumes.

Malathi Adusumalli is an Associate Professor with the Department of Social Work, University of Delhi and has vast experience in the field of community development. She has authored a number of articles and contributed to the knowledge volumes in Social Work. Her doctoral work was in the area of Development Studies and she has continued her research interests in the state of

xxx Editor and Contributors

Uttarakhand, particularly with disaster affected communities. Her interests are in the fields of social development, gender development, social policy and social research.

Lakshmi Narasimhan has a Masters in Social Work and has been working in the homelessness—mental health space since 2005 with The Banyan. She leads the implementation and research of projects aimed at quality of life gains using community-based approaches to mental health. Dr. Narsimhan has served as the principal investigator and project lead for action research projects at The Banyan. These include NALAM, a well-being oriented, multi-interventional, tiered clinical and social support service spearheaded by community mental health workers; and Home Again, a housing with supportive services intervention offering exit path- ways out of institutionalised care for persons with severe and persistent mental illness. She is currently engaged in a multi-site community re-entry programme to address issues of long stay and incarceration in institutional facilities. Her interests are in understanding and developing social approaches for complex issues at the intersection of poverty, homelessness and mental health.

Uma Parameswaran has completed M.Phil. in Clinical Psychology and is cur- rently working in a research project.

Vibhuti Patel is Professor, Advanced Centre for Women’s Studies, School of Development Studies, Tata Institute of Social Sciences, Mumbai. She retired as Professor and Head of Economics Department of SNDT Women’s University, Mumbai on 30-6-2017. She was Director, Post Graduate Studies and Research of SNDT Women’s University from 2006 to 2012. Her areas of specialisation have been Gender Economics, Women’s Studies, Human Rights, Social Movements and Gender Budgeting. She has authored Women’s Challenges of the New Millennium (2002. She is co-editor of series of 15 volumes—Empowering Women Worldwide. Her edited books are Discourse on Women and Empowerment (2009) and Girls and Girlhoods at the Threshold of Youth and Gender (2010). She had been a member of various Expert Committees for IGNOU, Ministry of Science and Technology and NCERT (Delhi) during 2005–2014.

Anupama V. Prabhu is a Psychologist and Special Educator, has 9 years of experience in community based psychological care. She is involved in conducting various awareness sessions to different segments in community. Anupama also has experience in dealing children with special needs.

Barbara Regeer is Assistant Professor at the Athena Institute, VU University Amsterdam. She has Bachelor degrees in Physics and Philosophy and a Master’s degree in Science Dynamics. She has analysed and developed interfaces and interactions between science and society in various ways throughout her career. She conducts her research on emerging innovative strategies for sustainable develop- ment. Dr. Regeer has been involved in numerous (inter-) organisational change processes, with a specific focus on enhancing learning between all actors involved, in such areas as sustainability innovation programmes (agriculture, urban

Editor and Contributors xxxi

development, mobility), care farming, disability mainstreaming, youth care organisations, and psychiatric institutions. She has initiated the development of Translearning and other reflection tools such as the Dynamic Learning Agenda and Eye-opener workshops.

R. Srinivasa Murthy has been a full time academician/researcher from the time of completion of postgraduate training in 1975. He was a faculty member at PGIMER, Chandigarh (1975–1981) and the National institute of Mental Health and Neurosciences (NIMHANS) Bangalore (1982–2003). Prof. Murthy was Professor of Psychiatry at NIMHANS, from 1987 to 2003. He was Head of the Department of Psychiatry, from January 1988 to February 1997 with over 50 postgraduates and 40 academic staff. He has been a much-respected teacher and mentor to many of the current leaders in psychiatry in India. He was a staff of World health Organisation (WHO) during 2000–2001 (Chief Editor, World Health Report, 2001-Mental Health) and 2004–2006 (in the WHO-EMRO Office). Since retirement, he has provided honorary services to non-governmental organizations like the Association for the Mentally challenged, (AMC) Bangalore (2008–2014), Sri Shankara Cancer Hospital and Research Centre (SSCHRC), Bangalore (2015–2016). He was awar- ded the Distinguished Scientist Chair of Indian Council of Medical research, (ICMR), New Delhi in May 2016. Currently working to develop and disseminate ‘self-care skills’ for emotional health with a special focus on persons living with a diagnosis of cancer and HIV-AIDS.

Nilima Srivastava is a Professor and currently the Director with the School of Gender and Development Studies, Indira Gandhi National Open University, New Delhi. Her area of specialization is women and work. She has researched exten- sively on work-life balance of women workers in International and national context in diverse settings. She has written three books and published a number of research papers in national and international publications. She was a visiting Professor to University of British Columbia, where she carried out a micro level research to study impact of Federal and Provincial Governments’ child care policies on working mothers in Vancouver.

Ashwini Survase is working as Project Manager with Tarasha since 2012. She has completed her Masters in Counselling from TISS, and a Bachelors in Psychology and Sociology from Mumbai University. She is currently pursuing a Doctoral Degree from Advanced Centre For Women’s Studies, TISS. Before joining Tarasha, she worked as a counsellor with a daycare Centre for persons recovering from mental health issues. Her interest areas are mental health, gender and marginalization.

Abhishek Thakur is currently teaching at the Department of Social Work, University of Delhi, India. He has completed his Masters and M.Phil. degree from Tata Institute of Social Sciences, Mumbai. His research interests include Disability Studies, Labour and Employment.

xxxii Editor and Contributors

Saumya Uma is an Associate Professor at the Jindal Global Law School and has previously taught in the School of Law, Governance and Citizenship—Ambedkar University Delhi, Maharashtra National Law University, Mumbai and National Law School of India—Bangalore. Her areas of specialization are human rights, gender and the law. She has over 25 years’ of combined professional experience as an advocate, researcher, writer, trainer, campaigner and academic. Dr. Uma is a life member of the Indian Association for Women’s Studies and an active member of the women’s movements in India and in the South Asian region.

Sheena Varughese is currently working as Assistant Professor, Department of Psychiatry, Pushpagiri Institute of Medical Sciences, Thiruvalla, Kerala. She had completed her MD Psychiatry from St. Johns Academy of Health Sciences and Medical College, Bangalore. Her area of interest includes Child and Adolescent Psychiatry and Addiction Psychiatry.

Chitra Venkateswaran is a Professor of Psychiatry and Palliative care physician. Having wide experience not only in Kerala, working initially in the WHO col- laborating centre in Calicut but also as a trainer and mentor across India. Active role in work that highlights an important perspective on the neglected area of chronic mental health and palliative care with its priority area within NCD programmes. She holds the role of founder/clinical director of Mehac Foundation, a not for profit based on a palliative care model. Mehac strives to deliver exceptional care to improve the quality of life of people with mental illnesses in the community. The goal is to improve the psychosocial component in any person with a special interest to facilitate integration of psychological issues in palliative care.

Anu Sonia Vincent has M.Phil. in Consulting Psychology, and has hands on experience working with student community and their families. She has around 5 years of experience working at school as counsellor. She is presently working as psychologist at Mehac.


AAA Ashray Adhikar Abhiyan
ACT Assertive community treatment
AD Alzheimer’s disease
ASHA Accredited Social Health Activist
BPAD Bipolar affective disorder
CM Case management
CRPD Convention on the Rights of Persons with Disabilities DALYs Disability-adjusted life years
DHS Directorate of Health Services
DOSMeD Determinants of Outcome of Severe Mental Disorders DSLSA Delhi State Legal Services Authority
DSM Diagnostic and Statistical Manual
ECT Electroconvulsive therapy
FGD Focus group discussion
GTBH Guru Teg Bahadur Hospital
ICD International Classification of Diseases
ICIDH International Classification of Impairments, Disabilities, and

ICM Intensive Case Management

IDI In-depth interview
IHBAS Institute of Human Behaviour & Allied Sciences
LAMI Low and middle income
LGBTQIA+ Lesbian, Gay, Bisexual, and Transgender Queer, Intersex and

MEHAC Mental Health Care and Research Foundation MHA Mental Healthcare Act
MTP Medical Termination of Pregnancy
NGO Non-governmental organization
NHRC National Human Rights Commission
NMHS National Mental Health Survey of India


xxxiv Abbreviations

PMDD Premenstrual dysphoric disorder
PMS Premenstrual stress syndrome
PPD Post-partum depression
PTSD Post-traumatic stress disorder
RPDA Rights of Persons with Disabilities Act SE Supported employment

SHG Self-help group
SMI Severe mental illness
SSRI Selective serotonin reuptake inhibitor
SZ Schizophrenia
UDHR Universal Declaration of Human Rights
UNCRPD United Nations Convention on the Rights of Persons with

UNFPA United Nations Fund for Population Activities WHO World Health Organization

List of Figures

Fig. 1.1 Fig. 12.1

Fig.15.1 Fig.16.1

Socialdeterminantsofmentalhealth………………… 6 Proportion of men versus women in long-stay service-users atstatepsychiatrichospitals………………………. 175 Conceptofthemodel…………………………… 228 Sevenkeyprinciplesofstrengthpractice……………… 238


List of Tables

Table 12.1

Table 12.2 Table 12.3 Table 12.4

Background characteristics of women admitted to emergency
care and recovery centre (ECRC), The Banyan, 2014–2017 (n=203)………………………………….. 180 Admissions and discharges from the emergency care andrecoverycentre(ECRC)2014–2017n=203………. 181 Clients reintegrated from ECRC and length of stay by year ofadmission……………………………….. 182 Current aftercare status of clients discharged tofamilies/facilitiesoutside……………………… 183


List of Boxes

Box 3.1

Box 6.1 Box 6.2 Box 6.3

Box 8.1 Box 8.2 Box 8.3


Gender Disparities and Mental health: The Facts (WHO2020)…………………………………. 35 Recent headlines of the times during #METOO movement. . . . . 80 7 Habits that women must learn to change (Narayan 2018) . . . . 85 Seven Levels to address male–female relationships that promote mentalhealth…………………………………. 91 Biological Differences among Men and Women with SZ . . . . . . 114 Government Entitlements under of Disability Certification . . . . . 115 Key points: Social Differences among Men and Women withSchizophrenia…………………………….. 120 RoleofaSocialWorkerinEnsuringGenderParity………. 122


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