Working as a lecturer and counselor in a college setting, interaction with the age group of 18-22 year olds, has made me acutely aware of the growing need to incorporate modules of mental health development in the regular curriculum. With the educational system’s lopsided thrust on academic success alone, the realm of mental well-being has been almost completely neglected in mainstream educational programs. The emphasis of the educational system is mainly on rote learning, under the garb of achieving academic excellence. If we observe a cross section of the student population today, we would realize that their analytical skills have not been developed at all, as the emphasis of the curriculum is exam oriented rather than knowledge acquisition.

Students gradually start equating marks with their "life worth". Accompanying this "success based formula" of achievement is a whole baggage of frustrations due to inability to handle failure, cut throat competition and pressure of grades oriented parents. Our educational setting sadly fails to address the stress levels that adolescents are facing today. In fact it acts as one of the contributory factors in increasing the stress levels. There is a need for us to take a serious cognizance of this fact.

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Anand Pawar

Adolescence is recognized as an age of difficulties, caused by the rapid physical, emotional, intellectual and social changes that accompany it. Adolescents struggle with newly encountered obstacles such as awkwardness, self-discovery, independence, educational demands and puberty. Even though the developmental stage of adolescence has not dramatically changed over the past twenty years, today’s adolescents are living in an environment that is more complex and contains a greater amount of negative influences.

Problems for adolescents are increasing all the more in the present clock-driven, fast paced, competitive, profit and achievement obsessed modern society. Compared to a few decades ago, today’s kids are spending less time with adults and spending more time in front of the television and with peers. These changes require acquiring new skill sets for coping. However neither the Indian educational setting has been of much help in the development of essential life skills, nor are the parents of much help as they themselves are confused and scared to handle these fast paced changes.

I have interacted with several adolescents who seek counseling on a wide range of issues. Many of them approach with relationship related issues like dating, friendship or family problems. Many of them find it difficult to draw boundaries in relationships or are unable to be assertive, and as a result are often taken advantage of. They are overwhelmed by the emotions they experience in these relationships and are unable to handle them. Some have difficulty in initiating and maintaining relationships, inspite of the strong desire to do so. These interpersonal difficulties seem to form the focus and are a cause of many stress related manifestations.

Many students seek intervention for exam related anxiety, however at the base of it lies their attitude of placing undue importance on marks, fear of accepting failure and the lack of basic problem solving skills, including organizing, scheduling, deciding priorities etc.

problems associated with their social conditions, namely economic difficulties, gender bias in the family, and parental problems.

Interventions today in the area of adolescent psychology are of a curative nature. Very little emphasis is being placed on the preventive aspect of mental health. The studies carried out in preventive mental health are mainly focused on decreasing risk taking behaviours and antisocial behaviour. However along with decreasing risk taking behaviors it is also necessary to improve the emotional health of adolescents and equip them with skills to face the challenges of the future. I strongly feel that including training modules on life skills will definitely help reduce the intensity and incidence of psychological difficulties faced by the students.

The WHO (1994) has listed out the major life skills essential for emotional well-being and happiness. They are- decision making, problem solving, critical thinking, creative thinking, effective communication, interpersonal relationships, self-awareness, and empathy, coping with emotions and coping with stress.

We need to aim towards raising the emotional and social competence in youth as a part of their regular education, not in remedial mode but as a set of essential skills. The most effective approach would be a three fold one, where intervention and advocacy is carried out simultaneously with the student, the parents, and the teachers. The efficiency of the training would be optimum if the program could involve maximal factors that affect the adolescent’s well being, two of the most influential being the family and the educational setting. Peer related issues could be discussed in the training sessions. The modules could include

For Teachers and parents:

		Awareness regarding normal adolescent development
		Recognizing stress and stressors in adolescent
		Facilitating adaptive coping behaviour in the adolescent
		Awareness regarding various psychological disorders, especially in adolescence
		Information regarding support systems that parents could approach in case of psychological difficulties.

This could be carried out either in a non-curriculum based approach, where it is treated as a stand-alone subject; or a curriculum based approach where life skill modules are incorporated into regular lessons, without taking separate classes for the modules.

One of the reasons that the youth are poor in basic life skills is that as a society we have not bothered to make sure that every child is taught these essentials. By leaving the emotional lessons children learn to chance, we risk wasting an opportunity to help them cultivate a healthy emotional repertoire.

It is high time that educators and professionals from the fields of psychology advocate the need for inclusion of these essential skills with a thrust on positive mental health and emotional well-being.

The Committee on Safety of Medicines is one of a number of independent advisory committees established under the Medicines Act, which advises the UK Licensing Authority on the quality, and safety of medicines to make sure public health standards are met and maintained. The CSM is there to provide advice to the Licensing Authority on whether new products should be allowed to market themselves in this country. They must also monitor the safety of medicines already being marketed. Members of the committee include pharmacists, pharmacologists, toxicologists and physicians from a wide range of disciplines working in general practice, hospitals and universities across the UK. See www.socialaudit.org.uk for more regarding this.

Drug Tracks-II

A local newspaper had an article about the necessity of old age homes. The subsequent issues of the same newspaper were full of responses to that article. Most of them were discussing the role of old people in the life of the busy youth. That reminded me of following story.

This happened in a space and time when every living being had to pass through three stages in life namely: childhood, youth and old age. The spirit of youth of all creatures was living in a stream. The spirit of old age was in a huge gigantic ocean. The stream and the sea had to stay close by. Enjoying its own being, the stream used to run joyously, till the end of a cliff and jump down from there. Many people would relax by the bank of the stream. Even birds and animals would come there for the sweet water. And the reflection of the stream in the ocean would look magnificent.

The well being of youth cannot be discussed in isolation from adulthood or old age. Different systems of medicine have thought over the reasons of well-being and ill health. As per the basic assumptions of that system the reasons and remedies may vary. However, two conclusions seem to be common in all these systems, 1) In different stages of development human beings are vulnerable to different sorts of ill health and 2) Prevention is better than cure.

The well being of youth is necessary for the wellbeing of the society at large. It is all inter-related. Young people show us the truth of what Shakespeare said, that the sorrow of youth lies light on the shoulder of youth. The youthful energy and enthusiasm of working tirelessly, does attract many towards them. And still we see many of them restless, and frustrated. Some intrinsic or extrinsic factors add fuel to this frustration. In fact ever looking forward, restless to achieve further dreams is a sign of life. However care should be taken that this restlessness does not become unwellness.

At the Center for Advocacy in Mental Health, Pune, we are running a campaign against the use of direct ECT (Electro Convulsive Therapy without anesthesia). This campaign follows in the wake of the recent Supreme Court Judgment, approving of the procedure, and the shocking promotion of the practice by psychiatric professionals recently.

In direct ECT, an electrical current is passed, which throws the body into epilepsy like seizures. While the patient is conscious in the beginning, he or she is rendered unconscious when the grand mal seizure starts. He is held down physically to prevent fractures and internal injuries. In an ideal situation, the procedure is repeated between 6 to 10 times. But continuous dosing up to 20 times or more is not unknown or uncommon in India. In its "modern" or "modified" form (Modified ECT), muscle relaxants and anesthesia are given to reduce the overt epileptic / muscular convulsions and patient anxiety. The muscle relaxant paralyzes all the muscles of the body. A "crash cart" is kept nearby, with a variety of life-saving devices and medications, including a defibrillator for kick starting the heart in case of a cardiac arrest. The brain is subjected to seizure activity induced by the electrical current. The causal mechanism by which the treatment works is not known. Endocrinological, neurotransmitter and other changes have drawn a blank. It is believed that electricity itself and the seizure activity it produces is the curing element.

To make a case for direct ECT in this day and age, establishes a fresh, new low for psychiatric ethics in India. Instead of debating the issue of ‘whether or not ECT’, and what community alternatives we can create in mental health, we are placed in this ridiculous situation of debating direct ECT.

Many European countries have phased out even modified ECT, while in the US its usage has come down drastically after the 1980s, following class action. The 1978 APA Task Force reported that only 16% of psychiatrists gave (modified) ECT. In the West, two important factors led to the phasing out of direct ECT: one was the discovery that between 0.5% to 20% of patients suffered from vertebral fractures; and the second was their evident terror and trauma. Kiloh, et. al. (1988) give this long list of common "complaints" following ECT, which are more acutely experienced when given direct: headache, nausea, dizziness, vomiting, muscle stiffness, pain, visual impairment due to conjunctival haemorrhages, tachycardia/bradycardia, BP surges, changes in Cardio Vascular activities, alteration in blood brain barrier, ECG changes, arrhythmias, cardiac arrest, ventricular fibrillation, sudden death, dysrhythmias, transient dysphasia, amenorrhoea, hemiparesis, tactile/visual inattention, homonymous haemianopia. Among the "risks" mentioned are the following: myocardial infarction, pulmonary abscesses, pulmonary embolism, activation of pulmonary TB, rupture of colon with peritonitis, gastric haemorrhage, perforation of a peptic ulcer, haemorrhage into the thyroid, epistaxis, adrenal haemorrhage, strangulated hernia, cerebral haemorrhage and subarachnoid haemorrhages. Infrequent "complications" that arise may be fractures (vertebrae, femur, scapula, humerus) and dislocations (jaw, shoulder), cardiac arrhythmias, apnoea and "tardive" convulsions. Among the inevitable "side-effects" are mentioned, cardiovascular responses, postictal clouding of consciousness and memory impairment. With modified ECT, the effects are "less likely" but not completely ruled out.

The Bombay High Court recommended against the use of direct ECT way back in 1989, following the Mahajan Committee Recommendations. In Goa, due to legal advocacy and the proactive role of psychiatrists there, direct ECT has been banned. Death in the case of ECT is usually due to cardio-vascular or cerebral-vascular complications, followed by respiratory failure. A high percentage of patients do report fear and apprehension of the procedure, which professionals do not consider as a serious or a competent refusal. They address the refusal as one more psychiatric symptom for which they give sedatives. The European CPT (Convention for the Prevention of Torture) 2002 prohibits the use of direct ECT as a form of torture. Victims of direct ECT should be considered as victims of medical torture and brought within human rights and medico-legal jurisprudence.

In every city, a majority of private practitioners give ECT in their private clinics costing anywhere between 500 to 1000 rupees per dose. For a minimum of 6 doses, the cost would be between 3000/- to 10,000/- rupees. As readers of aaina may be aware, there are psychiatrists who ask the patient to first take an ECT before even consultation. ECT has been given to cure "naxalism" (Ramaswamy in Aaina, Vol. 1). In private practice, it is difficult to have the medical back up necessary to give anesthesia or for resuscitation. ECT guidelines do not exist in India, making it conducive for doctors to engage in rampant abuse of the procedure. The situation here is similar to sex selection tests as the private market rules the roost.

In our view, direct ECT is a matter for human rights law, prevention of torture instruments, regulation and consumer litigation, and it is not for academic discussion. We have serious objections to conduct of research on direct ECT. World history carries adequate evidence of the barbarity of the procedure. Statutory authorities, human rights commission and medical regulatory bodies must proscribe such research.

I have been teaching graduate and post-graduate students for the last thirteen years. I have also been interacting with youth through various formal and informal fora like NSS, Tarun mandals, discussion groups, counselling, support groups and social organizations. This has enabled me to play the multiple roles of teacher, friend, cousellor and confidante. It has been a privilege to share their trials and tribulations, successes and struggles.

Well-being is a state of well being which comes from being rooted in the self. This concept of health is in alignment with the concept of swasthya proposed by Ayurveda. The World Health Organization has also proposed the bio-psycho-socio-spiritual model of health, which looks beyond the physical symptoms and focuses on the well-being of the person. Two important things for the sense of wellbeing of youth are, the work that one chooses, and secondly, relationships. Youth is the time when everybody dreams very high. But very few have the courage to live as per their dreams. Choosing the work, which they would love to do, and looking beyond the external measures of security, prestige, money, or glamour, helps him or her to be rooted in the self.

Due to natural energy very few young people would be unwell. However there is a high risk that this energy be misdirected. It is the prime responsibility of adults to help the youth to choose wisely. And when the castles built by youths develop roots in the ground with the wisdom and the folly of the earlier generation’s experience, the well-being of youth does not remain a dream.

As readers of Aaina are aware, direct ECT was placed as a controversial and contested issue before the SC recently, following the Erwadi deaths in Tamil Nadu. In Writ Petition No. 562/2001 in Saarthak vs. Union of India, the petitioner had asked for a complete ban on direct ECT.

The response of the state and the judiciary to the use of direct ECT has been ambivalent. In response to the SC inquiry, many states have reported that direct ECT is being phased out and that, as per modern practice, only modified ECT is being used in their "mental health institutes". Some states have given a justification for continuing the use of direct ECT, while also certifying that in their State this practice is not being followed.

In its final judgment, the apex court noted that "ECT remains effective in several major mental disorders", that it is "life saving" and reduces the "risk of suicide". It further states, notoriously, that direct ECT is safer than modified ECT, as in the latter the risk of use of anesthesia and muscle relaxants is added.

Dr D Mohan, Psychiatrist, AIIMS, New Delhi, advised the apex court in this instance. The doctor observes a mortality rate of "only 0.03%" in direct ECT, considered as clinically insignificant. Dr Gauri Devi, erstwhile director of NIMHANS, wrote observing mainly that modified ECT is a non-issue in the treatment of certain mental disorders. But she did not frontally address the issue of direct ECT, the central topic of the Saarthak litigation.

The main purport of the Saarthak litigation, viz about quality of care, was completely unaddressed by the esteemed court. The court has considered it necessary and sufficient to only pronounce the procedure as "safe", without any regard for the vexed question of how it is administered in practice. The AIIMS professional, for his part, did not give the background database about direct ECT, or explore the controversy surrounding it, even as a matter of informing the court. Instead of treating this as a quality of care issue and as an investigative matter, he simply certified the procedure as safe, raising the concern about questionable authorisation. The court, on its part, considered the 2 letters received from the doctors as sufficient for its judgment.

This judgment has extensive implications for the future of mental health service delivery in India. Through this judgment, the Supreme Court has given a big boost to the bio-medical profile and future of mental health in India. In promoting direct ECT, our highest court has the dubious privilege of being one of the few such, world over, to sanction a procedure considered as barbaric and obsolete.

Lesbians are often accused of being self-indulgent or even elitist because of their preoccupation with matters related to that most taboo activity: sex. Sexuality is a secondary issue, they say, it is not as important as food or water or employment or even communal violence. To them I would say, is it possible to say that your eyes are not as important as your feet or as your fingers or as your tongue? Sexuality, as Audre Lorde says, is that vital and nourishing aspect of your being where life’s driving impulse, desire, finds one of its expressions. It belongs like faith, to the realm of the highly personal, where the most delicate human aspirations are realized, broken, refashioned or grappled with. It is the well of that experience which we call the inner life; it is the battleground of deeply held fears, limitations and beliefs. It is also that terrain where we can find sustenance, where we can begin to love ourselves a little more or then, learn something about who we are and what we are becoming. Sexuality entangles our past and present in such a way that it becomes one throbbing state, compelling us to experience the whole range of human emotion and moving us in ways that we cannot imagine. It forces us to look at ourselves without shame and to accept, with courage, what we find. In fact sexuality is the evidence of the incompleteness of, what left-wing liberals have eloquently criticized as, the ‘atomization’ and ‘mechanization’ of human sensibility. If we miss the significance of this area of activity, we become what Adrienne Rich calls "literal beings", sensible only to the most gross influences and persistent only in the fulfillment of the most animal needs.

the organized responses of our colonized minds and bodies. We fall in love with the wrong people, of the wrong caste, the wrong gender, the wrong sex, the wrong class, the wrong nationality or the wrong marital status. And we are punished for it, either directly by the society that we live in, or then by internal torment. But the liberty to love and to shape that love is ours, determined as it is by a deeply personal stirring. Of course love needs to be regulated, not by the prescriptions of received structures, but by a sense of our own ethics and by intelligence. However, even beyond the multiple and intangible ways in which sexuality constitutes our beings, the decisions women make about their sexual identities can become a source of very real conflict and threat. Women’s lives often hinge on the simple fact of whether they love a man or a woman, or whether they love this ‘kind of man’ or that ‘kind of woman’.

any case; the stigma associated with same sex love and then with suicide further obliterates lesbian suicides from view. However, reports from the press keep pouring in at regular intervals and it is likely, for the reasons given above, that the problem is most likely grossly underestimated rather than overstated.

How do we understand these suicides? What do they mean and why do they happen? Suicide, suicidal attempts and ideation are urgent problems amongst youth today. A suicide attempt is a cry for help; it is the ultimate declaration that the pain the person is experiencing exceeds the resources for coping with the pain. People are driven to suicide out of deep despair and a feeling that there is no other way out… No other way out. The crisis appears so insurmountable that it seems easier to take one’s life than to overcome it. The attempt to take one’s life comes only after repeated and strenuous efforts to overcome the distress or to address its cause. Often suicide is at the end of a continuum of harassment, stressors, coercion, violence and general thwarting of one’s will. This repeated stress has already worn down the person’s coping mechanisms which may already be stretched to the limit, while self-confidence and belief in oneself is also generally low. At such a time a person is most vulnerable to making a suicide attempt.

They had sought help from the police and were receiving psychiatric treatment at the time of death. Their bodies were found side by side on a rock near an irrigation canal close to one the girls’ houses in Moolamattom East, Kerala.

The reports go on and on and cannot be reproduced here in entirety. In Kerala alone there were 21 reported cases of lesbian suicide in the span of six years, from 1995-2001. Information about the suicides is often sketchy or incomplete, but there seem to be some common patterns in the factors that contribute to the suicide. Often there is a mention of forced marriage, one or both of the girls are being forced into a marriage that they do not want, but which they feel they are powerless to stop. There is frequently an admission that it is impossible to live without the other person and, even though not stated directly, the suicide attempt itself conveys that the women feel it is impossible to live with the other also. In some cases, there are incidents of overt harassment from family or employers. Parents have tried to confine their daughters indoors for months together, to batter them physically and emotionally, to beat up their lovers, or then to report the couple’s flight as a case of kidnapping by the lover. There are reports of involuntary discharge from government service, and of prolonged forced isolation without food at the workplace. Where there are no signs of overt harassment it is clear that the families of the girls either do not know or then clearly disapprove of the relationship. Another recurring pattern is the feeling of guilt that the girls themselves feel about loving each other and about causing their families "distress".

and feel guilty for loving, like they almost deserve death because they did the "unthinkable". This homophobia creates tremendous frustration and confusion for women because it gives them almost no room to love with dignity. The violence, social stigma, self-hatred and outright discrimination at work, often with a complete lack of support or affirmation from family and friends, can create a situation of extreme distress for women. Women who have committed suicide have had limited means or resources at their disposal. They are students who have no livelihood of their own, they are daily wage labourers, or women with little access to formal education or employment.

In small towns and rural areas especially, women who love women are completely isolated from any kind of support system. Often they have not even heard of other women who love women, are not aware of groups or people who could help in a crisis situation and cannot conceive of a viable alternative to marriage. This goes back to the whole problem of the general invisibility of lesbians in public space, as it is dangerous for women to be "out" in a hostile atmosphere, but this danger also prevents women from finding out about each other and imposes a silence on them. Homophobia prevents women from getting the help that they need when they most need it. It is tragic that at times young women have not even attempted to tell friends or family about their love and have chosen instead to end their lives because they know what is in store.

What can we do to make it safer for women who are confronting homophobia and who are battling great odds to find a freedom that was always theirs?