On 11th March, 2002, the Indian Medical Council has issued a notification on the "Professional conduct, etiquette and ethics" Regulations, 2002. The regulations are applicable to all "doctors with qualification of MBBS or MBBS with PG degree / diploma or with equivalent qualification in any medical discipline". Psychiatry, being a medical discipline, comes within the scope of these regulations.

aaina is a mental health advocacy newsletter. Advocacy demands critical, creative and transformative engagement with the state, policy makers, professionals, law, family and society at large. aaina will thematically cover issues in community and mental health, NGOs in mental health, self-help and healing, non-medical alternatives in mental health, rights, ethics, policy and needs of special groups. aaina provides a forum for user expression of their experiences with mental health services and debates issues concerning rights of persons with psychiatric disabilities. We look forward to meaningful dialogue with individuals and groups alert about these issues.

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The appellant, the husband of the respondent, filed a petition seeking a declaration that their marriage was null and void because of the mental illness suffered by the respondent. Section 12(1)(b) and Section 5(ii) of the Hindu Marriage Act 1955 were cited as grounds. The couple parted company after 25 days of marriage. The appellant charged that his wife suffered from a chronic and incurable mental disorder and was not in a fit mental state to lead a married life. Her "drowsiness" and "refusal to have cohabitation" apparently moved him to further investigate and find out that she was suffering since childhood from a mental disorder, a fact which her father allegedly admitted to. The respondent refuted all the allegations, claiming that the respondent’s motive was for a bigger dowry and a second marriage. The trial court had dismissed the petition on grounds that the petitioner could not prove unsoundness of mind. While admitting that it had no medical expertise, it did so after having had the "privilege" of watching the respondent give witness, the way she clearly answered questions and her general demeanour.

The appellate court found fault with the trial court for not having considered as "evidence" the prescriptions issued by a psychiatrist from Chennai. Unlike the trial court, the appellate court accepted the fact of separation. It also took serious note of the respondent’s admission to having suffered a mental disorder and that she was given depot injections. The case was once more opened.

The appellant filed in the apex court, assailing the judgment of the High Court under Article 136 of the Constitution. After studying the relevant sections, and dismissing the husband’s appeal, the Supreme Court held that these sections, if established in a court of law, do disentitle the party to a valid marriage. Since marriages are voidable (and not per se null and void) using these sections, such cases "in the very nature of things call for strict standard of proof", the onus of bringing such a case before the court and the proof being "very heavy" on the party seeking annulment. The court pledges to examine the matter with "all possible care and anxiety".

Accepting as facts both the presence of mental disorder as well as the separation, the apex court held that this was no basis for inferring that the respondent was unfit for marriage and the procreation of children. It would be, in the court’s view, an unreasonable and impermissible inference. To make this inference, it needed to be further established that the ailment is of such a kind or to such an extent that it is impossible for her to lead a normal married life. It would be fair to read the law in this manner, according to this honourable court. The relevant sections and the burden of proof enshrined in them require a far more stringent interpretation than that accepted by the appellate court. Further, the High court may also be faulted for not formulating an appropriate question before law as mandatory. However, considering the manner in which the case has proceeded until the high court, the court could not be faulted for having dismissed the petition and the apex court did not find this a fit case for interfering with the HC judgment. The appeal was dismissed.

Historically the State has always been oppressively paternalistic in its attitude towards persons labeled with mental sickness. Most laws, including the Indian laws, are testimony to this. What is so special, so abhorrent about the "mentally ill" that they have been singled out among a million others who fall sick everyday? For example, why is someone suffering from diabetes or cold allowed the luxury of seeking homeopathic treatment or even trying homegrown herbal remedies? Any ill person is just ill and therefore, has to be treated without compromising his freedom in any way whatsoever.

Firstly, unlike other people suffering from physical diseases, the "mentally ill" are supposed to have lost their capacity to take responsible decisions.

Secondly, psychiatry, not so respected within the hierarchy of all medical disciplines, and in its strife to be like a true science, has produced a dichotomy between the body and mind, where the mind is reduced to a mere brain. Psychiatry has very little to do with the mind. The "psyche" part has all but been surgically removed from it. Psychiatry is rooted in German experimental psychology, racist eugenics theories, and anti-human materialistic opinions parading as scientific facts. The promotional activities and tremendous profits of the major drug companies must be clearly recognized for any accurate understanding of the expansion of psychiatry. Psychiatry ignores all comprising man’s "inner" world of thoughts, feelings, values, aspirations, hopes, dreams, fantasies, desires, intentions, goals, and ultimately, life itself.

Fourth, the reason why the State has been traditionally inhuman in their treatment of the "mentally ill" has been because the "mentally ill" have been perceived to be "lesser humans". This is a mindset that still rules in society throughout India, China, North America and other parts of the world. The "mentally ill" by virtue of their temporary and at times, fleeting loss of reason, are the world’s most "muzzled" individuals.

Finally, psychiatry, with active encouragement by the State, has a long and ignoble track record of blaming social and economic dysfunction on its primary victims. In the 1800’s psychiatry pathologised the tendency of slaves to run away and called it "drapetomania", a "disease" which no doubt called for heroic "therapies". During the industrial revolution, it found its calling in the imprisonment and torturous experimentation on the unemployed poor. Domestic abuse and adverse social conditions are major factors in the creation of "mental illness", yet science continues to prescribe drugs for "unbalanced brains." The modern "scientific-secular" family has reposed its faith in the goodwill of the doctors. It seems, to adapt a quote from Richard Nixon, "If a doctor does it, that means it is medicine."

Everybody believes that the side effects of drugs are transitory in nature. Actually, it is the mental state, which is transitory, yet nobody can believe this except the "mentally ill" themselves! There is also a period of reckoning, introspection, self healing and remission for the person, which again seems incredulous to society. This positive development is naturally attributed to the psychiatric medicines. Even while everyone says that the "mentally ill" must be responsible for their own "treatment" the healing process is credited only to the medicines. All this reinforces the myth that the drugs are harmless, have little side effects and that they work to restore the bio- chemical imbalance in the "mentally ill" person’s brain.

In June, a continuing medical education program of 15 course credit hours on "Non-Pharmaceutical Approaches to Mental Health" was organised by Safe Harbor, a leading non profit organisation in the US educating the public, the medical field and government agencies on the use of alternative mental health.

Dan Stradford, the president, in his introduction, pointed out that psychiatry does not take the effects of drugs very seriously. Putting on 60 kilos of weight is a primary and very risky health effect of anti-depressant use, this cannot be called a "side effect" by any standard. Other than the health and brain damaging effects of psychotropics, such drugs do not address the root causes of the mental symptoms, which means life long use of risky drugs to obtain mere symptom relief. The overemphasis on drugs inhibits personal growth, as it limits individual creativity in dealing with crises and it creates an artificial state of mind.

The objectives of the program were to educate on (1) medical conditions that present as psychiatric symptoms (2) hormonal causes of emotional disturbances (3) nutritional treatment and herbal remedies for anxiety and depression (4) lab testing for underlying causes of mental symptoms and (5) sharing case histories of successful recoveries using alternative mental health. Behind the many inspiring and experienced lecture presentations consolidated in this unique program, remains the pioneering work done by biological psychologist Abram Hoffer. The experts were mostly from the fields of psychiatry, psychology, nutrition and biology.

There was a demonstration of the enormous lab testing possibilities in the presentation by Jeff Baker from the Great Smokies Diagnostic Labs. After outlining the molecular basis of what he called "chronic metabolic disorders" -(we call them "mental disorders"!)-, Dr Baker talked about lab testing for amino acid deficiencies, metal poisoning, hormone deficiencies, vitamin and other nutritional deficiencies. It was so surprising to know that chronic candida, a common reproductive tract infection in women, can cause a range of mental experiences including fatigue, poor memory, being "spacey", insomnia, hypersomnia, anxiety, and mood swings.

Dr Charles Gant (MD, Ph D) who wrote on the Natural treatments for addictions, compared the conventional approach to treatment of mental disorder with what he called the GANTS method, a method which recognises the role of Nutrition, Toxicity and Stress in the causation of mental symptoms. An important intervention step in these presentations is the examination of the nutritional and toxicity status of individuals. He concluded that "The number one health problem in the US and probably the entire world (alcoholism) is not being addressed in a rational, efficacious, scientific and safe manner. Until such scientific principles are brought to bear on the treatment of addictions it is unlikely and probably impossible for substantive improvements in care to occur".

mental disorder, it was evident that minor to major mental ailments could well have organic causes that are misdiagnosed. Mercury poisoning (children’s vaccines, dental fillings, effluents from coal fired plants, contaminated fish), other fungal, environmental, metal and gas poisoning, problems with adrenal and thyroid secretions, vitamin and other nutritional deficiencies were discussed. These lectures showed that with modernisation and mechanisation, as our food culture, eating habits and environment changes, we can expect a great impact on physical as well as our mental health. This seems such a self evident lesson, yet it needs to be taught.

Other fascinating presentations included Dr Gant’s "Complementary solutions for children diagnosed with Attention Deficit Disorder", Dr Hyla Cass’ "Nutritional and herbal remedies for depression" and Dr Cynthia Watson’s "Role of Hormones in mood disturbances". The role of various essential fatty oils in child brain development, vitamin deficiency and mental disability in children, using common herbs for treatment of depression, hormonal treatment for dealing with reproductive health linked mental changes, etc. were some of the themes that were discussed in these presentations. The program ended with moving stories of recovery by using diverse, and for us, here, hitherto unexplored tools, for example, acupuncture and hormone treatment. The claim which Dan started out with, that a psychotropic drug is not a natural body nutrient, and let us use alternatives to drugs, was well validated through the program. For the first time, I met so many mental health professionals who were trying out a wide variety of solutions to address individual mental health needs, instead of just pushing prescriptions.

Saarthak, a voluntary organization from New Delhi, has filed a petition in the Supreme Court (Civil writ petition No. 562). Their petition has asked the apex court to issue necessary directives to each state and union territory for complying with setting up statutory authorities under the Mental Health Act, 1987. The petition challenges the constitutionality of Section 81(2) of the Mental Health Act and says that this section is violative of human rights. This section provides that a mentally ill person may be used for the purposes of research, if such research is of direct benefit to him for purposes of diagnosis or treatment. It further provides that when such person is a voluntary patient, he may give his "valid" consent for such research or where such person is incompetent to give his consent, by reason of minority or otherwise, the guardian or other person competent to give consent on his behalf can give consent in writing for such research. The petition argues the inadvisability and "barbarity" of ECT without anesthesia and highlights the risks involved (bone fractures and other bodily injuries; problems with ECT in general, such as confusion, loss of memory and back problems). While the petition admits that modified ECT may be beneficial, it talks about prescribed guidelines even in such cases. The petition prays for avoidance of physical restraint and confinement, except under "extreme" circumstances, where guidelines would specify assessment of risk to self and others. Even when used, such practice, it is urged, should not be an indefinite one. 6 hours is being suggested as acceptable period for review, which would be done by a Medical Board. The petition appeals for the prohibition on chains and persuades the use of alternatives such as cotton bandages or sedatives in extreme cases. The petition persuades the provision of "psychiatric therapy" [sic!] and proper facilities for rehabilitative counseling, and quarter way homes. Patients should be informed about the legal aid services provided for by statute.

(Papers shared with us by Mr SK Ravi of Action Aid India, New Delhi)

"In Gujarat, mental health professionals have been working with violence victims in government hospitals and relief camps. However, the response has been feeble when compared to the Bhuj earthquake. The most important reason for this is the fear and uncertainty of the situation. Second, the sanction of violence by a large majority has affected mental health professionals as well. Gujarat needs a long-term plan for community based psychosocial intervention using volunteers. Every victim has a right to mental health relief for a reasonable period, provided by the State. Research or assessments must include an action component; victims should not be viewed as a laboratory. Counsellors must plan to work on long term conflict resolution and move to the centre of the disaster zone, not hide in the periphery. In Gujarat, the mental health fraternity was silent fearing the disruption of "therapeutic neutrality". This is a denial of professional responsibility. Mental health professionals need not be sloganeers, but they must raise sane voices during difficult times. [O]n the whole, silence has transformed the profession’s empathy into apathy. This collective silence must be broken with concerted action towards healing and prevention".

Dr Harish Shetty, Psychiatrist, MAITRI, Mumbai in Issues in Medical Ethics, Vol. 10(3), July-September 2002.

- Values herself as an individual and as a female rather than depreciating herself as a woman

- Chooses behaviours according to their suitability and to the situation, deliberately resisting conforming to female gender stereotypes and certainly not conforming to them unwittingly

- Consistently tends towards emotional, social and economic self-sufficiency, striving for separateness and autonomy before seeking interdependence

- Blends autonomy with interdependence in the form of a selected number of deep relationships with others in personal and social activities

- Appreciates differences as much as similarities, preferring variety in herself and others to
stereotypes

- Does not victimise herself, does not let herself be victimised, and does not present herself as a victim

- Enjoys the power of her emotions and her self, and displays this power through vivacity and
energy

- Orients herself toward reality and realism, avoiding  overreaction in favour of accepting herself, others and the world for what they are

- Takes risks and extends herself without placing too much emphasis on either success or failure

From Arrows for Change, "Women’s Well-being: Reframing Mental Health" Vol. 7, No. 3, 2001 (www.arrow.org.my)

Dr Dhanda- The SC took suo moto notice of the Erwadi incident. On its own, it asked the chief secretary of the TN government to file an affidavit reporting exactly what happened. They came to know of cases where persons labeled mentally ill were being kept in very inhuman conditions in other states also. So they asked all states to file affidavits. Saarthak, an NGO, also filed a petition, not raising issues such as Erwadi, but raising the question of giving unmodified ECT to patients. It also raised questions relating to psychiatric research being carried out which are not directly benefiting the patient. There is a provision in the mental health Act that allows this. The MHA says that you can carry out experimental or beneficial research on a person with mental illness with her or his consent. But equally, you can also do it without the consent whether the research is directly beneficial to the individual or not. The Saarthak petition is asking for removal of this provision altogether as unconstitutional. About ECT, they are saying that unmodified ECT should be banned, that the persons who administer such ECT should be criminally prosecuted and that a committee of NGO representative, social worker and a psychiatrist should regulate ECT practice. Saarthak has also asked for the implementation of the statutory provisions of the MHA, such as the State Mental Health Authority, the licensing authority, etc.

The Saarthak challenge is to the MHA provision that research can happen whether beneficial to the patient or not; and whether he or she gives consent or not. They are saying that using surrogate consent is unconstitutional. There are indeed problems with these provisions, but a number of people are saying that maybe you should have a closer look before writing off the whole thing as unconstitutional. If the provision was struck off altogether, it would discourage mental health research which in the long term may work against the interests of persons with mental illness. The petition could have suggested the setting up of ethics committees on a mandatory basis or a more public centric process of scrutinizing research. There is a problem with surrogate consent. The problem is that there is a thin line between consent with understanding and consent with undue influence. But rendering the provision for conducting research altogether as unconstitutional would prohibit even such research where valid patient consent is there. What if a patient or a class of patients want some research to be conducted, which they feel is beneficial to them? The petitioner could have asked the court to read up that provision in more plausible ways, which will limit the scope of surrogate consent and give greater validity for patient consent. This way, both the interests of the patient autonomy as well as the right to good quality care could have been upheld. If you were to strike it down today, then tomorrow you will have to start the process all over again because of the feeling that law should permit such research, which is in the interest of the patient.

But the statute does not speak about it. In the case of persons diagnosed with a mental illness, it may be wise to have a statutory protection. Such a ruling by the SC would also give legal validity to ethics committees in general, giving such committees more teeth.

services, facilitate rehabilitation and restore civil status this is an absolute basic right. These questions are absent. The full implementation of MHA is not going to be a solution.

No, it is not. The minimum standards of care mentioned therein are all quantitative, such as ratios of doctor/nurse/patient, physical infrastructure. There is no mention at all about the quality of care. It is not in the Act nor is it in the rules. The Act is basically about entry and exit from mental hospitals, which was there in the Lunacy Act anyway. So, if in 2001 or in 2002, you are filing a petition in the apex court, and you are only asking for the implementation of the Act, and actually believe that the implementation of the Act is going to make for a better deal for persons with mental illness, you are living in a world of fancy.

There is a need for placing general principles of care and treatment within the law, and to recognize that the psychiatric patient needs an active protection, but the content may not find a place there.

For the first time, nearly every one, lay persons as well as professionals have woken up to the tragedy evoked by Erwadi, to the fact that a certain segment of society is living under such conditions and are treated like that.

"Self-help support" in groups for persons suffering from mental illness and their caregivers is relatively a new concept in India. We have been working as a self-help support group (Ekalavya) in Pune, India for last three years since 1997. However, we have had a feeling that our quality of work was not up to the mark for the following reasons: a) The number of members was not increasing b) We were lacking a neatly defined structure c) Some members as well as some professionals were skeptical about usefulness of a support group. These problems made us realize the need for a more organized approach for future growth.

Last year, as Secretary of the Pune chapter of the Schizophrenia Awareness Association, I was extended an invitation to visit some mental health organizations in the USA. I prepared for this trip both individually (through an introductory correspondence course for mental health facilitators) and within the Eklavya group through discussion. The immediate objectives of my trip were to help us redefine our aims and objectives, to enable us to conduct our group activities in a more skillful way, and to assist us in designing and producing educational materials to support our activity. The most critical area, it seemed to us, was defining the procedure for group meetings. We were learning by trial and error, but that has its risks. We felt the need to learn from other groups who were more experienced and working successfully. 

I reached New York on 29th May and left from New York