I do not know of anyone who has not known addiction personally – through themselves or their friends and family. This strange empirical statistics occurred to me when in a conversation with a friend I noticed how difficult it really was to break the nicotine cycle. He had been smoking since his late teenage years and decades later, decided he needed to stop. It wasn’t easy. He became a compulsive runner instead. Most of us have felt the compulsion of an early morning coffee without which we are dysfunctional for the greater part of the morning. Seemingly innocuous aperitifs and digestives consumed all over the world as part of meal routines can also lead to display of addictive tendencies of the population as a whole.

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Anand Pawar

Two videos give a very good description of Vipassana in prisons: "Doing Time, Doing Vipassana" is a documentary about the practice of the meditation in Tihar jail and "Changing from inside" documents Vipassana experience in the North Rehabilitation Facility. While the focus of both these documentaries is the transformation of the criminals, several inmates have claimed recovery from their addictions in these documentaries.

Zen like Vipassana is a meditation technique that emphasizes self-awareness and observation. Based on the same techniques taught by Buddha, the practice of Zen meditation differs slightly due to the influence of several great Japanese masters. Like Vipassana, it claims that attachments and cravings arise due to erroneous belief in permanence of sensations or events. In Zen, there is no "core self", everything about the self is impermanent since we transform each moment, erase and create new sense of personal identity. Zen meditation revolves around "zazen" sessions, which involve brief twenty-minute periods or so of mindful, or awareness, meditation performed sitting and are followed by a walking meditation. In Awareness or mindful meditation, the practitioner observes the feelings within their body and remains aware of every passing sensation. While the observations need not be cyclic like Vipassana meditation, the entire focus is on the painful or pleasant sensations within the physical body. To help concentrate, one may observe respiration or count the inhalation and exhalation, experiencing it in its totality. The walking meditation or "Kinhin" allows people to move and stretch after a sitting period and is especially suited for people whose span of concentration is limited due to the effect of various chemicals. In Kinhin, practitioners learn to be aware of their feet, the effect of walking on their physical state and the effect of the external environment on them. They learn to be objectively aware of these effects on their physical body and learn not react to it. By not reacting to the external stimuli, practitioners do not feel the aggression associated with an unfavourable event or experience ebullient joy when they encounter something very pleasant. This enables them to understand pain, anger, joy, depression and other human emotions and to remain equanimous under all circumstances.

Excellent resource materials are also provided by former addicts who have used Zen meditation to help recover. Mel Ash’s "Zen of Recovery" is a recount of the author’s recovery from alcoholism using Zen meditation. He shows how it can be combined with another program such as the 12-step program of the Alcoholics Anonymous for efficacy. Bill Alexander’s "Cool Water: Alcoholism, Mindfulness and Ordinary Recovery" describes how simple mindful techniques of Zen provided him with an ordinary recovery from alcoholism. It allowed him to actualize the ordinary human life unfettered by cravings for alcohol.

Zen and Vipassana are not instantaneous solutions to the problem of addiction. Its efficacy is not immediate. The greatest advantage it offers is that the person assumes responsibility for their life and through awareness gains an understanding of both the existence and the nature of their addiction. Often times the meditation sessions might themselves bring to forefront painful memories and emotional disturbances. The discipline in both these techniques can come in handy during such times. Determination and social support from the people around can also ensure constancy of practice. Awareness is the first step to higher consciousness. Meditation techniques such as these allow one to live in a constant plane of well being without having to shuttle back and forth between the highs and lows associated with addiction. Ultimately each person will need to decide this question for himself or herself.

Sujata Manohar, erstwhile Chief Justice of the Kerala High Court and member of NHRC spoke about the NHRC initiatives. She spoke about the rigid social mindset, which makes it very difficult to ensure that human rights of people be respected. Even within institutions, the conditions are often horrifying. There are many states (Rajasthan, Tamil Nadu, Sikkim, Delhi, West Bengal, Jammu and Kashmir, Karnataka, Manipur, Assam and Orissa), which keep the mentally ill chained within prisons even today. Mental hospitals also have jail-like structures including high walls and barred windows, to protect society from the inmates. However they provide little protection for those who are supposed to benefit, as can be seen from a number of pregnancies, which take place there, clearly indicating the sexual exploitation of residents.

self determination are recognized as important values for users of mental health services. When one admits to feeling mentally unwell, everyone automatically robs one of the autonomy to make personal choices or decisions. This over-protection eliminates the user’s role in self-care. Medications hardly provide one with the required time for self-introspection and healing. In practice, prescriptions, side effects, etc. are never talked about with the user. Psychiatrists often also connive with pharmaceutical companies to prescribe only those drugs for which they receive an incentive. There is no rational drug therapy in psychiatry. ECT should also have a law regulating its indiscriminate practice. Psychiatrists never make appropriate referrals (to clinical psychologists, for example) and claim expertise in areas where they have none (therapy or counselling). The backbone of the medico-legal system in mental health is about defining mental illness on the basis of concepts of "danger to self and the society", "being unfit", "incompetent", "not having capacity" and so on. There has to be guidelines created about determination of mental illness in medico-legal contexts. Often it is left to subjective whims and fancies of psychiatrists called upon to certify. Such bad practices must be thwarted with necessary litigation.

There are doctors who first ask the family to go to the ECT room for a dose, even before having a consultation. Often rehabilitation is center-based, when it should be community based. Building capacity among the users towards self-care, increasing their threshold for management, dealing with fears and apprehensions and decision making, transfer of skills to the home situation, etc. need to be addressed along with vocational skills. Carers too need help to manage the illness more effectively for which their judgement about when to let go and when to protect becomes very important. A course on psychotherapy is desperately needed. Carers’ fear of relapse, crisis management, managing medication and individual needs must be addressed more meaningfully, instead of with subjective, vague symptomatic instructions.

In rehabilitation "incapacity" must be replaced with "reasonable adjustment".

Community based rehabilitation is an important step in mental health today, but it lacks sustainability in many cases, as they are program or projects based. This has been taken into consideration by an organisation in Bangalore known as Humanitarian Hands, which essentially picks up vagrant and wandering mentally ill persons of the streets. CBR (Community based rehabilitation) covers all aspects of individual, family and community, keeping the gap between users and service-providers very clearly in mind. On the individual basis, the question of availability of medication does arise. One still finds cases of persons being administered traditional neuroleptics, which have very serious side effects. Also, sometimes, no matter what the level of disability, the family wants the person to contribute to income-generation in one way or other. Supportive therapy and coping skills are also very important since one tends to loose focus on this many a times. Users may sometimes be so overwhelmed by the trauma of severe mental illness, that they may lose self realisation in the recovery phase. Infact, many users attempt suicide, not in the ill phase, but in the recovery phase. Also, the gender aspects of rehabilitation needs more attention. Families do want to know the difference between "symptom" and "normal" behaviour, and their threshold for tolerating behaviour may be extreme. Building creativity within institutions is an important rehabilitation task, which is sadly missing today. Doctors and organisations, which practice exclusion of acutely sick patients, must be sensitised and taught new skills in crisis management. Community-based rehabilitation is a value-based partnership between mental health professionals and users.

The joint secretary from the woman and child department announced the scheme of "Swadhaar", under which various categories of women would be covered. This includes the category of mental health. The Indian Psychiatric Society initiative on IDEAS was shared. The therapeutic community approach of the RFI and the role of family therapy in rehabilitation were outlined.

Advocacy for mental health linkages in RH

Gender stereotypes, reflecting societal norms and imperatives underline the popular understanding of health as well as illness. This has had tremendous impact on the lives of the women, especially their reproductive health. Besides a look at the various national and international agendas clearly convey the narrow approach towards reproductive health. They have primarily linked it to fertility and population growth rates. Due to this limited focus the reproductive health policies have become tools, used by the State and the market, to dictate, control and medicalize the bodies of women. It is only recently that gender equity and women’s reproductive rights and health have found a mention in these policies.

After the 1994 International Conference on Population and Development, the World Health Organisation has defined reproductive health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity in all matters relating to the reproductive system and to its functions and processes." Irrespective of this global shift, the various reproductive health policies revolve around maternal and childcare and lately infections, in the back drop of the increasing rate of deaths due to HIV/AIDS. The other aspects related to reproductive health like menstruation, issues related to sexuality, infertility etc. remain unattended even today. In this background the total negligence of mental health component of reproductive health can be easily understood, though not justified. This is true of both mainstream work as well as advocacy in reproductive health.

But the literature, being produced in this arena, is purely psychiatric and it has its own limitations. It does not address women’s experiences about body, sexuality and reproductive health in a holistic manner. The impact of the socio-economic conditions, culture, gender, interpersonal relationships of the woman is often not addressed. There is tremendous under-recognition of these experiences and conditions by the health professionals as well as by the society at large. This breeds a "culture of silence" amongst the women forcing them to accept their ailments either as "normal" or "abnormal". Women usually bear ailments like pre-menstrual stress or other gynaecological morbidities mutely as they are socialised to accept these as a part of being a "woman" and thus "normal". On the other hand if a woman expresses her inability to cope with the demands of mothering she is looked at as "abnormal" and the condition is termed as a pathological condition.

The lack of consideration of the experiences of women affects their help seeking behaviour and hence it is crucial to understand the inner world of the women. Research directed towards understanding the linkages between reproductive health and mental or emotional well being of the women, from the women’s perspective, will have positive implications for framing gender sensitive policies and programmes. It will provide insight about the feasibility of integrating mental health aspects into the public health discourse as well.

At the "Right to Rehabilitation" workshop held in Delhi on August 24th, Dr R Thara (from SCARF) shared news about IDEAS, a tool for measuring psychiatric disability, developed by the Indian Psychiatric Society & SCARF, and accepted by the Central Government recently (Gazette of India, February 27,2002 (No.49) Notified by Ministry of Social Justice and empowerment).

Disability may be defined as a "difficulty in the performance of roles expected of the individual in his or her social and cultural milieu". Disability caused by mental illness is often invisible, unrecognized or ignored because of its variability, and there have been issues about measurements, making the implementation of the PWDA difficult. Earlier, professionals believed that prognosis can be made from clinical and diagnostic studies. However, this has proved to be a false hope. Valid measures of psychiatric disability are needed to understand patient prognosis, utilization, length and outcome of hospitalization, monitoring patient care, quality of care, improving treatments, social integration, rehabilitation and finally, improving policy and program planning: Welfare benefits, Insurance, etc.

Disability may traverse through three different dimensions: restriction, a limitation and then, an impairment. When we talk about impairment, this may be at the body or mental level, society, activities or participation. Dr. Thara shared news about other disability measurement tools in India, such as the Dysfunctional Analysis Questionnaire, the Schedule for Assessment of Psychiatric Disability, the SCARF social functioning index and the ICIDH. ICIDH is a system developed to describe, define, measure and classify the state of functioning (or disability to function) associated with health conditions(ie a disease, disorder, trauma or other health-related states).

Dr Thara explained that psychiatric disability, conceptually, is not linked with etiology. The diagnostic classification is put to use for the development of more rational interventions. The concept is useful for developing frameworks in cross cultural contexts, and also, it is now possible to link up disability with the civil rights movement. The ICIDH tool covers body functions, body structure, activity, participation and environmental factors. However, the ICIDH may be too sophisticated to be used at all levels of the public health system.

Dr Thara noted that the inclusion of mental illness in the Persons with Disability Act of 1995 is a landmark milestone in policy. The IPS was invited to develop a tool, which has now been accepted by the central Government, called IDEAS. The tool is simple and easy to administer, it covers all critical disability areas, it can generate scores, it is comparable to other disability measurements and it is sensitive to change. IDEAS covers the following dimensions of disability:

In its decision handed down on August 6th, the Netherlands Advertisement Code Commission (Reclame Code Commissie) ruled that the country’s Brain Foundation cannot claim that the controversial psychiatric condition Attention Deficit Hyperactivity Disorder (ADHD) is a neurobiological disease or brain dysfunction.  The Commission ordered the Brain Foundation to cease such false claims in their advertising. The Advertisement Code Commission was responding to a complaint brought by the Dutch chapter of the CCHR, an international psychiatric watchdog organization.

The Advertisement Code Commission found that the Brain Foundation had falsely advertised and solicited funding by publishing ads in newspapers, magazines, flyers and on TV that stated ADHD is an "inherent brain dysfunction." The Advertisement Code Commission decision stated, "The information that the defendant presented gives no grounds for the definitive statement that ADHD is an inherent brain dysfunction. Under the circumstances, the defendant has not been careful enough and the advertisement is misleading."

In the US, and elsewhere, several mental health professionals are successfully treating problems among children by addressing their nutritional deficiencies, against the tide of an increasingly aggressive processed food industry which is destroying any notion of holistic health among children. More information on the plight of millions of children subjected to mind-altering psychiatric drugs can be found at CCHR’s website http://www.fightforkids.com. For alternative approaches to treating ADHD, visit www.alternativementalhealth.com and its links.

Ms Tina Minkowitz represented the World Network of Users and Survivors of Psychiatry at the meetings of UN Disability convention. Her report for the Quadrennial review of the implementation of the World Programme of Action on Disability has been widely circulated through user networks all over the world. She and others involved in this initiative have called for world users to participate more actively in influencing the UN to attend closely to the rights of psychiatric survivors. Her report represents the views and opinions of various organizations and individuals around the world, including, Janet Amegatcher, attorney from Women in Law and Development (Africa), Janice Campbell (ECT survivor and activist), Sylvia Caras (peoplewho.org), Bhargavi Davar (Center for Advocacy in Mental Health, Pune), Mr. Sci. Reima Ana Maglalic (BiH, Bosnia & Herzegovina), Cully Downer (UK), Eric Rosenthal (MDRI), Mari Yamamoto (Japan National Group of Mentally Disabled People) and Laura Ziegler (activist, US). Here sections of the report on ECT practice and the situation in India are published. For the full report write to Tina Minkowitz (See her special report in this issue).

"In India, people labeled with psychiatric disability lose their civil rights to marriage, contracting, holding public office, and asset management. For this reason, it is left to guardians to apply for government disability benefits on the person’s behalf, and often it is done for the benefit of the family rather than the person her/himself.

Sometimes the ECT is done without even putting the person to "sleep" first. Only 35% of ECT is done with informed consent, and there is no legal protection for the right to refuse.

"A leading activist in the user/survivor movement reports, "In Japan there are only a few anesthetists, and most mental hospitals cannot get them or pay for them. Besides this, ECT is often given to punish patients and in such cases there is no time to prepare for anesthesia". A leading newspaper reported that in Matsuzawa Hospital, run by Tokyo local government, with 1368 beds, there were some 2000 electroshocks done in the year 2000, 1750 of which were done without general anesthesia, with body convulsions and only an injection of barbiturate. The newspaper also found that most ECTs were without informed consent and that ECT was overused to punish patients. This publicity spurred the report of the Municipal Hospital Association.

"Similarly to the situation in India, there is no regulation of the practice, and surrogate decision-making is predominant. Over 80% of the beds in Japan are in private hospitals and the public ones are relatively better for patients’ rights. Therefore it is believed that the statistics for informed consent quoted above are even lower in the private hospitals.

"People labeled with mental illness have often been overlooked or spoken for by others, when it comes to human rights. We believe that a Convention on Disability which respects all human rights, and protects the right to live as a person with a disability or as a person perceived to have a disability, will be of great value to us in asserting our rights. We also welcome the opportunity to collaborate with DESA, the Special Rapporteur on Disability, and other UN mechanisms such as the Office of the High Commissioner of Human Rights and the treaty-monitoring bodies."

The United Nations is negotiating a treaty on the rights of people with disabilities ("Disability Convention," more fully a "Comprehensive and Integral Convention to Protect and Promote the Rights and Dignity of Persons with Disabilities"). This treaty will join the other major human rights treaties, such as the Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, the International Convention for the Elimination of Racial Discrimination, the Convention for the Elimination of all forms of Discrimination Against Women, and the Convention on the Rights of the Child.

As survivors of psychiatric assault, we have an opportunity to influence this treaty and educate the world about the human rights violations we face. These violations, as you know, range from deprivation of civil liberties such as voting, to the terrifying experiences of incarceration, restraint and seclusion, forced drugging and electroshock. Also, because of discrimination and because the vast majority of us live in poverty we are vulnerable to having intolerable conditions imposed on us when we seek to meet our needs for housing, employment, income assistance, or voluntary mental health treatment. Often people suffer from deprivation of their basic needs.

For example, the Universal Declaration of Human Rights, the International Covenant on Civil and Political Rights, and the Torture Convention (plus regional conventions) make the prohibition against torture absolute ("non-derogable"). The definitions of torture appear to include forced drugging and electroshock, particularly the definition used in the Inter-American Convention to Prevent and Punish Torture, which prohibits the use of methods designed to obliterate the personality of the victim or to diminish his or her mental or physical capacities. We know that neuroleptics and electroshock "work" the way psychiatrists want them to by slow or fast brain damage, which creates psychic apathy and deprives the person of the ability to act spontaneously or creatively. This is seen especially in the use of neuroleptics and electroshock as restraint or in order to control behavior. A substance or procedure that works on the brain cannot control behavior otherwise than by diminishing the person’s mental capacity to act. There is some thought in the literature on torture that medical treatment justifies actions, which would otherwise be torture, but I think it can be shown that this de-values the individual and her uniqueness, which is a core value of human rights law.

The question arises whether we are disabled or only socially de-valued. I would argue that the philosophy of the disability rights movement, that disability is a social construct, gives us room to present our issues as we choose.

We also need to consider that the Disability Convention will likely purport to include us whether or not we take an active role in framing it. "Mental illness" was already included in the UN’s Standard Rules on the Equalization of Opportunities for Persons with Disabilities among types of impairments or conditions that give rise to disability. So our movement has to take some position about it. The approach of World Network of Users and Survivors of Psychiatry (WNUSP) so far has been two-fold – to raise consciousness by fighting for our core issues to be included, and to minimize the harm that can be done by ignorant or misleading language that could be used against us. I am interested in hearing other points of view, and very much welcome dialogue about any issues regarding the convention or the use of human rights law and principles to stop psychiatric assault. You can contact me at tminkowitz@earthlink.net or at the address below.

Tina Minkowitz, J.D.
91 Bradley Avenue
Staten Island, NY 10314
USA

We, at OLAVA, are deeply disturbed at the loss of Geethalakshmi and Sumathi’s lives. This incident highlights the lack of spaces and support for women who love women in India. The suicide of Geethalakshmi and Sumathi is one of the many lesbian suicides that have occurred over the last decade: two nurses in Meghraj, Gujarat, killed themselves in the local hospital quarters because they were to be separated by forced marriage; two young women who worked at a shrimp factory committed suicide on a railway track near Tiruvalla, Kerala, after their separation was imminent; another young couple