Mending minds, constructing care
The recent news about the alleged torture and killing of a resident in a Mental Health Centre in Peroorkada, Thiruvananthpuram, has yet again shocked the nation. From time immemorial, mental hospitals seem to be places that perpetuate atrocities and violate human rights instead of heal minds. In the 14th century, the first mental hospital, Bedlam, was set up in London in the absence of any scientific method of caring. What began as a refuge or asylum ended up being associated more with cruelty and ill-treatment of the mentally ill — a tradition one finds hard to break away from even today.
From straitjackets to induced seizures, from psychotropic drugs to psychoanalysis, mental healthcare has evolved and progressed in many ways. Today, most mental health issues can be treated in the community. However, at any given point of time, there is a small percentage that seeks institutionalised care, both emergency and long term, either because of uncontrollable suicidal instincts, poor treatment adherence, absence of a caregiver etc. For this group, sadly, things remain quite the same.
Hospitals that offer an environment that hastens recovery as well as long-term rehabilitation options for those who may require extended periods of care are a necessity. If these tertiary or community care centres are plagued by apathy, poor governance and indifference, how can some of the most vulnerable in our health system access safe and effective care? Sadly these atrocities always lead to a formulaic debate on whether or not hospitals are required in the first place. What would of course prove to be a more useful endeavour is to initiate reforms in the system and respond in newer, more innovative ways, both within hospitals and in other centres of healing.
At the moment, apart from a few exceptions from amongst the 42 mental hospitals in our country, the condition of most centres is abysmal. The rights of people are not respected and the facilities are far from satisfactory. Cells still exist in a few centres; some are barely lit; many are threatened with random administration of electro-convulsive therapy. Options to self-discharge and access recreational facilities and care grounded in principles of equity, justice and kindness are, of course, a distant dream.
Being the layered and complex issue that it is, to merely subscribe to a no institution policy could result in other forms of violence and violation. In the West, sudden and rapid deinstitutionalisation in the ’70s led to a dramatic rise in the number of homeless people on the streets. Several people with mental illness ended up in prisons instead of treatment centres. In India as well, the streets and the community are not always safe places. A few days ago, I rescued a young lady, visibly deluded, from an interior part of Chennai. Whilst some onlookers genuinely cared and wished to offer support, a section clearly was antagonistic and quite affronted by her unorthodox behaviour.
Similarly, some time back a homeless person with mental illness was perched upon a tree, scared to come down in the nights fearing rape. Yet another daughter tied her mother to a bed in Kerala for fear of losing her — she had jumped before a train twice earlier. All these people had accessed multiple sources of treatment, including alternate faith healing centres. The issue of an unsafe habitation and poor treatment perhaps is sometimes linked to the user’s socio-economic status. Those without financial resources are usually those who opt for government centres while those who are well endowed are in a position to seek better options that include healthier staff-client ratio, newer therapies and many modern amenities. Human resources that are scarce in this sector are unevenly distributed; with very few engaged in rural, state-run systems.
The National Human Rights Commission had pointed out many of these inadequacies almost a decade ago but somehow hasn’t seen through the implementation of the recommendations or reforms beyond the report stage. Wherever one has demonstrated change, whether in the government or non-governmental sector and set acceptable standards, one has seen effective leadership, clearly laid out protocols, a strong sense of principles that are non-negotiable and an ability to review and correct failing systems. Even in the Banyan’s 170-bedded facility, things are not always perfect. There are times when I witness poor hygiene, lack of activity and staff burn out. These are issues to contend with in most institutions and cannot be removed from the construct of care, but have to be dealt with effectively and with a sense of urgency.
While there is an urgent need to create guidelines that are plausible to implement, introduce better monitoring mechanisms and even overhaul systems if required to give way to smaller hospitals and more therapeutic spaces; there is also a need for spaces to open up in primary health centres and taluk and district hospitals. Non-compliance of any set norm should result in shutting down of the mental hospital and in serious consequences and penalisation for all responsible. This multi-pronged approach is the only way in which the problem can be addressed at its core.
Not all care needs to be located in mental hospitals. But when it does, the state and civil society need to a build a system that is firm in intent, dynamic in nature and enthusiastic to usher in a fresh and transparent culture that will truly help mend minds and rebuild person and trust. Like Mahatma Gandhi said, a nation should be judged by how it cares for its most vulnerable. There also is no reason why India cannot lead this initiative and share lessons with the world. After all, we are a nation that boasts of our rich social fibre and heritage.
The writer is the co-founder of The Banyan, a civil society organisation that works closely with people with mental disabilities and marginalised groups.