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Dignity In Mental Health

Dignity In Mental Health

Noted singer and songwriter, Bob Dylan in the 1960s sang, “The times they are a-changin.” And, rightly so! The country is in the middle of a political upheaval, held transfixed by the meteoric rise of the impresario extraordinaire, Prime Minister Narendra Modi. Left-wing resistance has taken charge of the young and pulsating academic spaces to weather the storm of tyranny. Romeo is no more a Shakespearean character, but a lustful miscreant prowling the streets waiting to pounce upon unsuspecting women. The humble cow is mummy in the heartland and yummy in the stomachland.

Yes, for the better or worse, “the times they are a-changin”. Yet, there is also reason for optimism. The Lok Sabha recently unanimously passed the Mental Healthcare Bill, 2016, a legislation that ensures persons with mental illness have the right to live a life of dignity and respect, without being discriminated against or harassed.

The main aim of the Bill is to provide for mental healthcare and services for persons with mental illness and to protect, promote and fulfil their rights and ensure the delivery of treatment and healthcare services.

World Health Organisation defines mental health as “a state of well-being in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community”. Health itself is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

The Bill defines “mental illness” as a substantial disorder of thinking, mood, perception, orientation or memory that grossly impairs judgment, behaviour, capacity to recognise reality or ability to meet the ordinary demands of life, and mental conditions associated with the abuse of alcohol and drugs. The Bill, however, takes care not to include mental retardation, which is a condition of arrested or incomplete development of a person’s mind, specially characterised by subnormality of intelligence.

Widely hailed for being progressive and rights-based in nature, the Bill stretches itself beyond legislative limits to display noble intentions. It strives to establish and strengthen systems that safeguard the fundamental rights of the patients and save them from the stigma associated with mental disorders.

In what can be understood as an indication of progressive thought, the Bill looks upon mental illness not as a disease but as a condition that can be cured with therapeutic treatment. The conditions brought into the fold of mental illness include attention deficit hyperactivity disorder (ADHD); anxiety disorders; autism; bipolar disorder; borderline personality disorder; depression; dissociative disorders; psychosis; eating disorders; obsessive compulsive disorder; post-traumatic stress disorder; and schizophrenia.

While the Bill is focused on providing proper healthcare, treatment and rehabilitation of victims of mental illness in a manner that does not intrude on their rights and dignity, there are several key provisions that stand out.

For starters, the Bill grants every affected individual the right to access affordable and good-quality mental healthcare and treatment from services that are run or funded by the government. Further, the Bill assures that there shall be no discrimination on the basis of gender, sex, sexual orientation, religion, culture, caste, social or political beliefs, class, disability or any other basis.

There shall also be provision for free treatment in case the patient is homeless or falls below the poverty line. It is not mandatory to possess a below poverty line card.

In an attempt to make procedures transparent and people-friendly, the Bill also outlines the process for admission, treatment and subsequent discharge of mental illness patients.

Besides this, the Bill provides for a distinctively empowering feature called an “Advance Directive”, wherein the person diagnosed with mental illness is given the complete freedom to decide the course of action of his/her treatment. The person shall have an advance directive that states how he/she wants to be treated for the illness and who shall be his/her nominee. The advance directive should be certified by a medical practitioner or be registered with the Mental Health Board. What is noteworthy is, with this move, the lawmakers are granting the power to decide to those who had hitherto been considered “incapable” of making sound judgement.

The Mental Healthcare Bill also brings into effect the establishment of a quasi-judicial body called the Mental Health Review Commission and Board, which shall be responsible for reviewing procedure for making advance directives as well as to advise the government on what steps to take for the protection of rights of mental health patients.

Another provision states that every mental health establishment has to be registered with the respective Central or State Mental Health Authority.

The Bill also has prohibited the use of electro-convulsive therapy, also known as shock treatment. This procedure is not to be performed on adults without administering muscle relaxants and anaesthesia, and is banned in all forms for children. Further, healthcare institutions and providers are barred from sterilising, chaining or abusing the patients in any form or manner. While these have long been considered a treatment modality that has saved innumerable lives, the Bill seeks to put a stop to it so as to not reduce individuals to a zombie-like vegetative state.

By far, the Bill’s most progressive feature is the decriminalisation of suicide attempt, which according to Section 309 of the Indian Penal Code is a criminal, punishable offence.

The Bill states, “Notwithstanding anything contained in section 309 of the Indian Penal code any person who attempts to commit suicide shall be presumed, unless proved otherwise, to have severe stress and shall not be tried and punished under the said Code.”

The frustrating and mostly isolating experience of fighting a mental disorder can sometimes lead to such eventualities as suicide. The National Crime Records Bureau calculated in 2014 that at least 15 suicides take place in India every hour. Fifteen suicides every 60 minutes are instances of our collective failure to recognise and solve the problem. This Bill brings to the table an opportunity for us as a society to do better about it.

The attempt to commit suicide may be regarded more as a manifestation of a diseased condition of mind deserving treatment and care rather than an offence to be visited with punishment.

The 210th Report of the Law Commission of India brought out in October 2008 undertook a keen examination of Section 309 and stated that it is a stumbling block for the prevention of suicide or self-harm. The report, titled “Humanisation and Decriminalisation of Attempt to Suicide”, found that the draconian and anachronistic Section 309 needed to be struck down immediately from the statute book because of the inhuman nature of the provision. An attempted suicide is a cry for help; it is not a crime. An attempted suicide is an indication of extreme mental distress.

In May of 2016, Health and Family Welfare Minister J.P. Nadda quoted from a 2005 National Commission for Macroeconomics and Health report – the last such comprehensive study available – to inform the Lok Sabha that nearly 10-20 million Indians (1-2 percent of the population) suffered from severe mental disorders such as schizophrenia and bipolar disorder, and nearly 50 million (5 percent of population) were victims of common mental disorders like depression and anxiety. Twelve years on, the numbers in our country have only increased and plead for urgent measures.

Another study estimates that at least one in 20 people in India live with mental illness. That’s about 5 percent or 50 million of the entire population dealing with a problem that is being acknowledged in all its gravity only now. By 2020, as much as 20 percent of our population might be affected by mental health issues. Yet, for so long the issue of mental health has been ignored, and if at all it has been dealt with, then it is with prejudice and ignorance.

Traditionally, the Indian system of treatment was designed to contain those affected with mental illness rather than to provide them with therapy and care. The first legal provision on the issue of mental illness was the Lunatics Removal Act of 1851, which was followed by the Indian Lunatic Asylum Act of 1858, the Military Lunatics Act of 1877, and the Indian Lunacy Act of 1912. These were all bequeathed to us by the colonial authorities, whose only answer to mental problems was to brand individuals as lunatics and confine them in so-called madhouses.

As a foreign power dominating subject people, it was easy and perhaps convenient for the British to incarcerate individuals and continue with the business of ruling as they saw fit.

The attitude of the British toward victims of mental illness during the crowning glory days of the British Raj was also influenced by the horrendous treatment meted out to so-called lunatics in their home country.

French philosopher Michel Foucault in his book “History of Madness” traces the evolution of the concept of madness through three phases: the Renaissance, the “Classical Age” (the later seventeenth and most of the eighteenth centuries) and the modern experience.

During the Renaissance, the mad (Foucault’s term) were seen as possessing a strange kind of wisdom and knowledge of the limits of the world. At the dawn of the Classical Age, however, the rational response to the mad was to separate them completely from society by confining them, along with prostitutes, vagrants, blasphemers and the like, in newly created institutions all over Europe – a process Foucault called “the Great Confinement.” In addition to getting rid of the undesirables, confinement also made the mad conveniently available to medical doctors who began to view madness as a natural object worthy of study and then as an illness to be cured.

The condition of mental illness victims took a turn for the worse during the modern era, at the end of the eighteenth century, with the creation of places devoted solely to the confinement of the mad under the supervision of medical doctors. These new institutions were the product of a blending of two motives: the new goal of curing the mad away from their family who could not afford the necessary care at home, and the old purpose of confining undesirables for the protection of society.

The British transferred to their subjects not just the stigma and shame associated with mental healthcare but also the image of a victim as a lunatic who should be ostracised in order to keep the society safe. Unfortunate as it is, this belief is alive and internalised in most quarters.

Even just before independence, in 1946 there was a government committee of enquiry which concluded that “the majority of mental hospitals in India are designed for detention and safe custody without regard for curative treatment.” This is largely continued as the pattern even after independence.

The Mental Health Act of 1987, which was recently amended, was first drafted in 1950 and it took decades of protracted measures and debate to get adopted 37 years later. By the time the Act was realised, it was already out of date. One of the main thrusts of the Act had been on protecting society from the presence of mentally ill persons – a reiteration of one of several baseless fabrications doled out by the British. It is no wonder Human Rights Watch has reported that inmates, particularly women and children, in mental health facilities were treated worse than animals.

But in an independent India, the government exists to serve the people of the nation. It is imperative that the health and well-being of our own people are looked after. We owe it to our people not to just brand them as lunatics and look the other way when help and assistance is asked. Even with the present Mental Healthcare Bill, it has to be admitted we are already late in rising to the occasion. Not only have our laws been stuck in this colonial-era mindset, our own mindsets with regard to mental health have also been frozen in time and history.

Mental illness is not just difficult to comprehend, but it comes with the colossal baggage of stigma in the way in which people are disregarded and shunned. If it is known that a person has been to a psychiatrist, or a shrink in modern parlance, then he/she is looked upon with fear and dread. A mental health patient is painted with the brush of ignorance and very often kept at a distance.

The truth, however, is this person is in dire need of medical assistance, help and understanding. It is a condition of the mind and not a behavioural pattern. The truth, of course, is mental illness is a very complex disability to gauge. If somebody has a broken leg or a fractured arm, it can be seen, but if somebody has a broken mind, it becomes extremely difficult to diagnose it. At times the affected individual looks perfectly healthy as far as appearances go. They come across as social beings even as they would be confronting painful inner battles.

Mental illness has always been discussed in hushed tones, but it truly crept into living room conversations with prominent Bollywood actor Deepika Padukone breaking the silence around her battle with clinical depression and anxiety. Her own experiences coupled with a friend’s suicide prompted her to start her own organisation, which seeks to champion the cause of mental illness.

However, how far have we reached in destigmatising mental illness or raising awareness is a question best left unanswered. Barely days after the landmark Mental Healthcare Bill was passed came the news that a 24-year-old jumped to his death after shooting a tutorial on suicide. After barely four steps – write notes to loved ones, get drunk, gaze at the view outside of the posh hotel room, eat pasta – Arun Bhardwaj bid adieu to the world. Bhardwaj had been battling a severe bout of depression. If only he had turned to someone for comfort in his moment of distress, he would still be alive.

Our treatment of suicide and attempt of suicide has been appalling as it is among the leading cause of deaths of young adults in India. On the one hand we sing songs about our demographic dividend and the potential of the youth, but we fail to realise how many of our young people are depressed. Familiar cultural networks are being replaced by new and unfamiliar systems at a fast pace. And because people are lacking an anchor, a steady base, at a time when our nation is undergoing rapid transformation, our young population is lapsing into disorientation. The need of the hour is to investigate what prompts them, or anybody else for that matter, to take such drastic steps.

The Mental Healthcare Bill is testimony to the changing times we are living in, however we have to change not just our laws but our mindsets as well, and that is the bigger challenge. It is a steeper challenge than just changing a law. And that is why this Bill must be accompanied with effective mechanisms for implementation. Let us assure our brethren are not fighting these battles of the mind alone, let us tell them we are here to help support and hold their hand until they are able to stand strong and lead a healthy, happy life.

(Published on 10th April 2017, Volume XXIX, Issue 15)#