Impact of Gender Inequality and Violence on Women's Mental Health: Narratives from a Halfway Home in India

Background and Aims: Poverty, restrictive gender roles, and gender-based violence disproportionately affect women in low-and middle-income countries (LMICs). In India, women with serious mental illness are a higher risk of experiencing sexual and physical victimization, poor social supports, homelessness, and abandonment in psychiatric institutions as compared to men. In the absence of family support, halfway homes support women in transitioning from institutions to communities. Research on the nexus between social inequalities and gender disparities in mental health within LMICs is limited. The Lancet Commission on Global Mental Health (GMH) acknowledges social inequalities as mental health determinants but falls short of translating this paradigm shift into effective solutions. There is an emphasis on scaling up individual-level behavioral services and limited attention to interventions that can address structural inequalities and prioritize social inclusion over individual treatment.  

Methods:

The present study was conducted with women living with SMI residing at a halfway home in an urban city in India. Guided by a narrative approach, 35 in-depth interviews (in the native language) with 11 women were conducted to elicit narratives related to illness, institutionalization, and community reintegration. In addition, ethnographic data (five key informant interviews with mental health providers and over 400 hours of documented participant observations and interactions between providers, women, and families), examined if there was an awareness among providers on how gender and social issues influenced women’s mental health.

Findings:

Participants lived at the halfway home for periods ranging from two months to 10 years with limited/ no contact with family. They carried a diagnosis of schizophrenia or bipolar disorder. Women attributed their illness to domestic violence; reasons cited for violence were early and forced marriage, dowry-related, and women’s ‘inability to perform their social roles’ owing to the illness. Women described involuntarily admitted to psychiatric institutions by families who were overwhelmed by the illness and/or who “intended to abandon them under the pretext of mental illness”. Women who were homeless after escaping domestic abuse and/or trafficking were admitted by the police. At the halfway home, women shared ‘feeling stuck’. Barriers to community reintegration were: 1) families’ unwillingness to support women, 2) women’s fear of going back to abusive families, and 3) limited livelihood opportunities that deterred women from living independently. Ethnographic data revealed that mental health services at the halfway home were dominated by western diagnostic categories, with an overemphasis on treatment and cure over recovery. Limited attention was paid to women’s contextual adversities and cultural expressions of distress.

Conclusion and Implications:

Indian women with SMI are spending prolonged periods in institutions and in dire circumstances, often over many decades. This is reflected in the relative ease with which women are institutionalized and the hurdles they experience to leave the institutions. In the absence of family support, interventions that can offer women structural supports (e.g., supported education, employment, legal protections) for their social integration are imperative. There is an urgent need for gender-inclusive implementation research in India and other LMICs that can address impact of gender-specific inequalities on women’s mental health.