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| Vol. 3 No. 2 |
November 2003 |
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| Editorial |
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| Another
Erwadi day slipped by this year, unnoticed and
forgotten.
The WHO inspired World Mental Health Day on
the 10th of October elicited enthusiastic response
from many regions. On this day, the State Human
Rights Commission of Maharashtra organised an
event on Mental health and Human Rights, covering
some human rights issues relevant to childhood
and adolescent mental health. The Maharashtra
Government gave away a coveted award to Shanti
Nursing Home, in Aurangabad, for maintaining
standards and outreach in providing mental health
care. Shanti Nursing Home, a psychiatric facility,
incidentally, has clearly articulated standards
as well as infra-structural facilities for giving
modified ECT. However, the event was funded
by SEVAC, an organisation of psychiatrists,
which clearly and unambiguously promotes the
idea of “pills for pain” ideology in mental
health. For some sceptics and those with strong
sentiments about local participation, there
was also the question of why SEVAC had to bring
their “expertise” (and their drug basket), all
the way from Calcutta to celebrate a local event:
Is Maharashtra so short on local resources?
The SHRC has offered to make a plan of action
for submission to the Maharashtra government.
Organisations and individuals in Maharashtra
could follow up with the local authorities for
the follow up on this program, where several
health and mental health dignitaries from the
government offices were present.
The Government of Gujarat has
recently released a 200 odd page comprehensive
report on the “Mental Health Mission”, under
the aegis of the Department of Health. The analysis
report is the result of 8 months of local research,
aiming towards collecting local data, which
will inform policy on the mental health needs
and interventions for the State of Gujarat.
Outside of service and finance issues, the Report
covers various topics, usually not found in
Indian policy documents on mental health, such
as stigma, communication strategies, women’s
issues, consumer and carer perspectives, ethics
and law. The report recommends the strengthening
of legal, ethical, regulatory aspects of mental
health as well as consumer advocacy and self-help
work in mental health in Gujarat. The document
is likely to be useful in policy making circles,
and the participatory process |
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The
Need for Legal Vigilance in the Treatment of Mentally
Ill Prisoners |
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Bibhas
Damodar Vaze |
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Earlier this year I was part of
a team investigating the law, treatment, and conditions
affecting mentally ill ("MI") prisoners
in Maharashtra state. Recent years have seen increasingly
sensational and brutal accounts of prisoner torture,
including the acidic blinding of people in Bihar.
And few need to be reminded of the burning beds
in a Chennai mental health facility, so one might
guess a combination of incarceration and treatment
would not be very healthy. Indeed, the conditions
and law relating to such prisoners have far to go,
but at the same time there was little in our preliminary
investigation that caused profound shock (though
I allow that time can desensitize us all). What
this indicates is that we are not at ground zero
in ensuring that the MI within the criminal justice
system receive both rights and treatment. Some awareness
does exist and there are institutions upon which
mental health advocates can and should build.
With a view to determining what
protection there is for the MI who find themselves
before the criminal justice system, our team looked
through both the criminal and administrative laws
at federal and state levels, and then conducted
preliminary fieldwork in two prisons, these being
the Pune Yeravda jail and the Ratnagiri Special
Prison. We also visited the mental hospitals and
judicial institutions in each area. Our objectives
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| Editorial
Team
Bhargavi Davar
Sadhana Natu |
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| Administrative
Support
Rupesh Kharat
Ramya Anand
Yogita Kulkarni
Rashmi Phadke |
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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.
Those interested in receiving copies
of aaina may contact us at wamhc@vsnl.net.
Write to us with all your suggestions, criticism
and viewpoints on the issues covered.
This issue of ‘aaina’ was
edited by Bhargavi Davar. |
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Design and Layout
Communication
Support |
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| Contact
Address
Center
for Advocacy in Mental Health,
B1/11, B1/12, Konark Pooram, Kondhwa Khurd, Pune-
411048.
Phone: 26837647.
Email: wamhc@vsnl.net |
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one, we wished to see what special administrative
procedures existed in the state and within each
prison to deal with the MI outside of the legislated
law, and whether such procedures were being implemented.
Secondly, keeping in mind that official power ultimately
determines treatment, we were concerned with the
attitudes held by officials who deal directly with
the MI, and the level of awareness they had both
about the law and of the idea that mental illness
is an illness. And finally, we wished to directly
see the living and treatment conditions for MI prisoners.
At the outset and at the end, the scenario we put
before both ourselves and officials was the most
basic: what happens –and what do you believe should
happen- at all stages of the process following the
arrest and incarceration of an MI individual.
A synopsis of some of the chief
findings follows. My ultimate conclusion is quite
banal; the submission is that extra vigilance is
needed to ensure that the rights of the MI prisoners
are respected. To understand this, we must understand
the theoretical premise which allows us to reach
such a conclusion.
Collective vs. Individual Rights
There has been a persistent conflict
between the ideas of collective and individual rights.
At the extreme, the former believes that some individual
freedoms must be sacrificed (by way of state action)
in order to ensure the collective “right” of overall
social welfare. The individualist paradigm essentially
posits unlimited freedom without responsibility
to the extent that such freedom does not interfere
with the voluntarily-exercised freedom of others.
Its extension is civil libertarianism, which includes
the view that officials should never be permitted
to sacrifice rights in favour of collective welfare,
as giving power to them to decide on the best social
outcome would allow for the arbitrary victimization
of individuals. In today’s context of liberalization
this debate has taken on a different turn; in India
we ask ourselves whether indigenous collective structures
are what we need, whether they be the family, the
panchayat, or the state, or if, in line with democracy,
we must adopt the individualist ethic which includes
the denial of social responsibility on the part
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As
always, the answer is about balance, but sometimes
this is not so easy because if one leans in any
direction there is always the possibility of toppling
to the opposite extreme. And so in a country of
India’s size, with limitations on oversight and
riven by unobjective or illiberal tendencies including
religion, caste, and language, one may inevitably
favour civil libertarianism, of absolute protection
for the individual rights of those who come before
the state, whether as MI, criminally accused, or
both. The idea is not to place a complete objection
to family involvement or social protection as a
whole, but that with so many interests at play,
and the potential for abuse being what it is, only
in very few circumstances should the interests of
others hold primacy over that of individuals. Therefore,
in order to ensure that there is no outside interference
or ulterior motive in official action taken by officials
in reference to MI persons, we must have due process
scrutiny.
As we see, nonetheless, the long-held western belief
that judicially-enforced liberties was all that
was required to protect people had the fatal flaw
of assuming that self-enforcing systems did not
require strong social involvement in order to be
successful.
The Law
For the most part the penal and
administrative law (such as the Mental Health Act)
does have a myriad of provisions protecting MI rights.
There are strong foundations, and an overall structure
with which to work, but also dangerous gaping holes.
For example, in the event that an accused is insane
at the time of trial, the presiding judge will indefinitely
postpone the proceedings until such time as the
accused is either well or competent enough to instruct
counsel. But there is no provision relating as to
how proceedings should ultimately be disposed of
should the individual never recover or fail to recover
within a specified time. It could result in the
horrific event (which has occurred in documented
cases) that, due to oversight, a person could spend
years or decades in jail for a minor crime that
was never even tried. Of course, officials state
that prosecutors, presiding magistrates and judges,
jailors, and mental health workers pay constant
attention to cases. But unfortunately one cannot |
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on the goodwill or vigilance of those who are often
overworked, overstressed, underpaid and who may
otherwise have an adverse interest. Similarly, in
the view of some mental health professionals we
interviewed, the penal law has completely failed
to adequately define ‘mental illness’ or ‘mentally
ill’, thus paving the way for arbitrary action to
be taken (or not taken) against individuals.
Administrative Procedures
The state of Maharashtra and individual
prisons have extensive provisions –some legislated
and some ad hoc- relating to the processing of MI
prisoners. Once again, however, they give way to
potentially uncontrolled action. In terms of deciding
when an individual is sick and requires special
attention or treatment outside the prison, for example,
the decision is in the jail superintendent’s hands,
based on the recommendation of a physician. However,
there are only two prison psychiatrists in Maharashtra
(in Pune and Nagpur) and in other cases the prison
doctor assesses who is MI. There are some problems
with this; firstly, the doctor may be employing
a restrictive definition of mental illness (which
we shall address next) and he or she may not even
be qualified to make such a determination (which
raises other systemic issues). Generally speaking,
the procedures appear to put strong power in the
hands of a superintendent, and overall, administrative
procedures appeared to be informal, ethereal, and
ad hoc. Whether they really existed in practise
or were made up was a question, and it raises concerns
about consistency in the treatment of prisoners.
The Definition of ‘Mental Illness’
If we were to assume for the moment
that the prisons were, indeed, doing their best
to determine who is MI and treating all those who
are ill, there would still be the problem of which
definition is employed. There appeared to be the
common conception that people were MI if they refused
to eat, if they were ranting and raving, talking
nonsense, or otherwise violent. But as we know,
mental illness can extend across much wider boundaries;
a person may suffer from severe depression and would
otherwise not be a threat to others, but that does
not make the illness any less severe or the need
for treatment less acute. Furthermore, we saw a
few people in the prisons who were clearly afflicted
(one woman had killed her children
and had all the indications of illness) |
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yet not defined as MI or given
extensive treatment. A further wrinkle is that when
some others were recognized as MI and expressed
violent thoughts, they continued to be placed within
the general prison population. The outcome, of course,
is that it leads us to question how many people
are suffering without being treated.
Awareness
For the most part, prison, judicial,
and law enforcement officials had a knowledge of
the fact that mental illness was an illness and
that MI individuals required special treatment.
No one, for example, expressed the view that it
was proper to beat or mistreat the MI, and both
high- and low-level prison officials said that it
was their duty to help those who suffered. How much
knowledge they had of relevant ‘laws’ or procedures
was difficult to determine. Once again, the MI must
depend not on the protection of the law but on the
extent of the general background officials have
in recognizing mental illness as illness.
Special Cases
We encountered a number of special
cases, which, if investigated further, would provide
excellent examples of how the law works –or does
not work- in relation to the MI. There was
the case that everyone was talking about in Ratnagiri,
of a brilliant young man, educated in English, Marathi,
and Gujarati, who misrepresented himself as a Supreme
Court Justice; moved from place to place, from hospital
to Court to prison, all the mechanisms of the law
had come into play. Then there was the instance
of a MI woman who committed a crime while in hospital
and was then put into prison with no one
paying attention until she became violent with a
courtroom clerk. And sadly, we had the experience
of meeting a young woman who, it seemed, was suffering
from illness and wanted to bring it to the Court’s
attention, but where was the lawyer to do so?
Conclusion: Legal Aid and the need
for Vigilance
There has been little doubt that
India’s legal aid system needs to be reformed so
that low-income and otherwise marginalized people
can truly have access to proper legal representation.
This issue becomes starker in relation to the mentally
ill. It furthers the idea that there must be action
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to provide a legal aid program
to the MI within the justice system.
I began by commenting on the difference
between the collective and individual approaches
to rights, indicating that many believed an industrial
or post-industrial society of India’s size required
the latter to ensure that criminally accused would
be protected. I did so to highlight a major theoretical
flaw, which is raised by our project. No system,
regardless of how many checks and balances it has
to protect people from state power, can survive
without those who are vigilant enough to speak out
and act in a manner that makes the checks and balances
work. It may be lawyers, judges, physicians, civil
society, or individual police officers. But somebody
has to ensure protection of those who are before
the system and cannot speak for themselves. The
MI do have voices of their own which must be heard,
and they need advocates on their behalf. For all
the gaping holes in the law relating to the MI in
the criminal justice system, there is a solid foundation.
But it will require vigilance to make it work both
socially and individually. In my view, a good first
step in this process would be in instituting a legal
aid system that can ensure there will always be
advocates protecting MI prisoners at every stage
of their struggle.
| (Acknowledgement:
In undertaking the study described, the
author acknowledges the extensive assistance
of Darshana Bansode and law students Varsha
Wankhade and Ayesha Sen Choudhary, and
the project guidance of Prof. Amita Dhanda.
As always, this project and my participation
would not have been possible without the
initiative, hard work, and patience of
Dr. Bhargavi Davar and the entire BAPU
staff.) |
The author is B.A. (Hons.), LL.B, Barrister-at-Law
of the Ontario Bar, Canada, and LL.M Candidate,
Columbia University. He practised as human rights
lawyer in Canada. Email: bdv2101@columbia.edu
; bibhasdamodar@yahoo.co.in
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1)
that the Government of Gujarat
set up in bringing out the report, may pave the
way for other state initiatives in mental health.
Organisations and individuals interested in taking
a dekho at this document could write to and
ask the state health authorities for more information.
Meanwhile, various consumer organisations
and mental health support groups around the world
are preparing to influence the proposed UN Convention
of Rights for persons with disabilities. One round
of Ad Hoc Committee meetings were over, and preparations
are on for the next one. This is certainly an initiative
that requires advocacy from the point of view of
psychiatric disability. We need to be more closely
in touch with the India office making representation
at these eminent gatherings.
The WHO initiatives in mental health
of "developing nations" has been gaining
ground, with many policy documents, training programs
and resource materials and manuals being prepared.
Critics of the WHO initiative in mental health argue
that the organisation is working too closely for
comfort with drug companies and with medical professionals,
to the exclusion of consumer or consumer support
groups. The rationality of stamping a western model
of care in culturally different zones is being questioned.
Several workshops and programs
have been held in different regions this quarter.
A workshop in Chennai was organised by Action Aid,
India, at The Banyan, to facilitate the formation
of a national level movement to address the overwhelming
care needs of wandering mentally ill persons. Every
bit of help or local initiative will be appreciated
and interested people could get in touch with the
Action Aid India, New Delhi office, for news on
this. Anveshi, Hyderabad, organised a meeting on
"Family and mental health", a brief report
of which is given here. The Center for Advocacy
in Mental Health, Pune, organised a program on ‘Alternative
mental health’ which promoted non-drug alternatives
to mental illness. Topics covered were homeopathy,
nutrition, hormonal treatments, play therapy, drum
circle, music therapy, dance therapy, neurolinguistic
programming, self help, story telling, etc. A full
report is available in print form from the CAMH
office. |
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UN Disability Convention-
Adhoc Meeting, 2003 |
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last category of disability on the Persons
with Disability Act, 1995, is the one
concerning disability due to mental illness.
There have been many consultations and
meetings set up by the UN towards developing
a Convention of rights for persons with
disabilities. Consumers of all disability
services, including psychiatric and rehab
services, all over the world are participating
in these consultations. Here, we present
the text of the statement presented by
Mr. A. Gopinathan, Deputy Permanent Representative
of India to the United Nations, for second
session of the Ad Hoc Committee meeting,
held in New York on the 19th of June,
2003. |
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"India is fully committed
to the realisation of social justice and the empowerment
of person with disabilities. We recognise the impact
of dual disadvantage and multiple discrimination
faced by specific groups such as children, women,
rural poor, severely and multiply disabled. In India,
in the past decade, the very concept of Rehabilitation
has been redefined from the perspective of an individual
pathology to that of an issue of human rights and
its accompanying implications for broader social
change.
"Over the past decade, India
has had the advantage of implementing three pieces
of legislation for the full participation of persons
with disabilities. The Rehabilitation Council of
India Act was enacted in 1992 for standardising
professional courses in rehabilitation and registering
qualified professionals. The landmark legislation
of Persons with Disabilities (Equal opportunities,
Protection of Rights and Full Participation) Act
was enacted in 1995 to ensure equal opportunities
for persons with disabilities, to prevent discrimination
and deprivation, promote participation in education,
training, employment, etc., and to provide for affirmative
action in creating accessible environments and to
redress the grievances of persons with disabilities.
The National Trust for the Welfare of persons with
Autism, Cerebral Palsy, Mental Retardation and Multiple
Disabilities Act was passed in 1999, which enables
persons with these four disabilities and organisations
for/of them to strengthen families in crisis and
provide for legal guardianship of persons with disabilities
beyond the age of 18 years. This Act also encourages
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Parent’s Associations where persons
with intellectual, severe and multiple disabilities
are themselves unable or unwilling to engage in
self-advocacy.
"The Government is working
at present with over 1500 NGOs in the disability
sector. Over 20,000 rehabilitation professionals
have been trained, registered and are practicing.
More than 6000 grievances have been redressed in
the last 3 years. There are over 750,000 students
with disabilities in the mainstream education system
where 1 million teachers in regular schools have
had training in inclusive education. Over 12,000
persons with disabilities have been employed in
the government sector alone. More than $ 10 million
has been disbursed as soft loans to 14,000 persons
with disabilities through the National Handicapped
Finance and Development Corporation of the Government
to set up self employment ventures. As many as 78,000
persons with disabilities have been included in
mainstream poverty alleviation programmes, mainly
in rural areas of India. Through the government
rehabilitation programme alone, almost 2 million
persons with disabilities have been served across
the country. …
"India believes that all disabled
persons have a right to opportunities for holistic
development. Any infant born with in impairment
or at risk of one, must have immediate access to
diagnostic services, appropriate medical/surgical
intervention, parent counselling, fitment of assistive
devices, where necessary, and also access to necessary
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development of the full potential
of the child with regard to activities of daily
living, movement, communication and cognitive abilities.
They may also need special support in their education
and employment for which appropriate services have
to be made accessible and available. Even though
many children can and are included in regular schools
and work places, the education system and the employment
market itself needs to be further modified and made
more inclusive supported through provision of appropriate
teaching/learning materials resource support, transportation
services, etc. Persons who become disabled in later
life through accidents, illnesses and degenerative
diseases also need access to rehabilitation services.
After the initial interventions, support may be
required for vocational training, access to higher
education and employment/economic opportunities
for earning a living.
"The process that is currently
underway in India is dual in nature with multipronged
strategies in extending the reach of rehabilitation
services on one hand as well creating attitudinal
changes in civil society which is essential for
a multisectoral convergent and inclusive society….
"While India is ready to examine
the need for the elaboration of a legal instrument,
it is essential that a number of issues be addressed
while considering the issue. It will not only be
necessary, but will be vital to ensure that adequate
resources are available and committed for addressing
the critical gaps between the actual needs and available
services. In many developing countries, including
India the population of disabled persons is large
and a majority of them are in their childhood or
in their productive period…
"Research in this area followed
by appropriate counselling can address the prevention
of causes of disabilities such as hearing impairment,
muscular dystrophy, retinitis pigmentosa, etc. …
"It is known that disability
is over – represented in the population which is
at or below the poverty line of the general population.
Their inclusion in poverty alleviation programmes
and in economic empowerment strategies is vital.
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"Affirmative action across
the board in favour of persons with disabilities
is strongly supported by India. Steps have been
taken to reserve seats in education programmes and
in Government employment for persons with disabilities.
However, additional support is required particularly
towards ensuring barrier free access to public buildings,
transport services, etc. Besides, all places of
employment education, recreation, entertainment,
etc. need to be done to make existing facilities
accessible and for ensuring that future buildings,
outdoor spaces and transportation reflects the needs
of persons with disabilities. This requires financial
investments of large magnitudes for a society like
ours, and provisions and mechanisms need to be incorporated
in the draft convention to provide for resource
flows for these purposes.
"Persons with disabilities
also need protection from discriminatory practices.
The Constitution of India provides this protection.
Besides, the persons with Disabilities Act, 1995
prohibits discrimination on account of disability.
Any legal instrument needs to have strong and adequate
provisions for protection of the disabled persons
from any kind of discrimination whatsoever.…
"India strongly believes that
any international legal instrument should aim to
protect and promote the rights of persons with disabilities
in all areas of their development as well as protection
from discrimination; and is therefore supportive
of a ‘hybrid model’ for any Convention.
"Any legal instrument should
ultimately promote and protect the full range of
rights of persons with disabilities including civil,
economic, social, political and cultural. A Convention
should set standards, which are not below standards
already established and contextual to member countries.
"The draft convention must
commit itself to facilitating opportunities that
empower and enable persons with disability through
training, care, income, and social inclusion, ways
and means of strengthening families, environments
that are free from physical, informational and psychological |
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barriers, ideologies and societies
that are inclusive in nature and access to programmes
that are affordable and available. …
"India will continue to work
towards a progressive realisation of all the fundamental
rights of persons with disabilities, reaffirming
their personal freedoms and need for autonomy, which
will inter alia reflect a paradigm shift from welfare
to rights and opportunities for full participation
and the creation of a society that is free from
barriers of discrimination, violation and denial
of equality, dignity and social justice to persons
with disabilities and their families.
"In furtherance of this goal,
the Government will strive for pervasive social
change, which permeates into mainstream activities
of community life so that persons with disabilities
in India can lead a life of quality, dignity, equality
and justice in a society, which is free from bias,
prejudice, stigma and discrimination."
Information on the convention
and present discussions on it can be downloaded
from the United Nations website. The topic of
"Disability due to chronic mental illness"
is not touched upon in the India representation.
Do write your concerns about this serious omission
to the India Representative or the Disability
office in New Delhi.
Address: Permanent Mission of India to the United
Nations, 235 East 43rd Street,
New York, NY 10017. Tel: (212) 490-9660. Fax:
(212) 490-9656 E-Mail: India@un.int
| Sorry...
... we made an error in our November 2002
issue, on the SC stand on ECT. The SC has
so far not commented on the use of ECT. However,
the GOI issued an affidavit to the SC, upon
advise from the AIIMS professionals, noting
the safety of direct ECT." |
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Moving
Towards Sex Positivity
A review by Pooja K. Khialani
"Wickedness is a myth invented
by good people to account for the curious attractiveness
of others."
–Oscar Wilde
Sex is commonly viewed as being
wicked, sinful and dirty. Nearly all of us learn
from a very early age that we need protection from
our sexuality. Instead of accepting sex as being
an integral part of our lives, we cultivate the
belief that sex is inherently bad.
In his article, "The language
of sex-positivity", Charlie Glickman, a
sex educator, focuses on how to break down negative
views about sex or, "sex negativity".
Glickman rightly explains how the first step to
changing negative attitudes regarding sex is to
create a new language to discuss sex. Glickman in
comparing sex and food, uses an interesting and
highly effective analogy to demonstrate how viewing
sex as being a normal and integral part of life,
would aid in moving towards a sex positive world.
Even those who maybe highly uncomfortable with discussing
issues regarding sex, are bound to find this analogy
quite convincing.
"Sex positivity"
is commonly defined as the belief that sex is good.
However, Glickman reframes sex positivity as being
"working towards a more positive relationship
with sex". This redefinition not only acknowledges
that sex is neither good nor bad but also recognizes
that each individual has a different relationship
with sex as it is a subjective experience. Moreover
it also demonstrates that an individual’s relationship
with sex always has room for improvement. Glickman
also succeeds in demonstrating to the reader that
sex is infact no different from any other basic
need of human beings. It is just that sex has been
overly hyped as being bad; hence leading to a world
that is largely sex negative.
Furthermore, sex positivity allows
us to stop questioning our own normality. In a sex
positive world, one would not have to worry about
being "normal" as comparisons with others
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to be important and "normal"
would be defined as what is normal for ourselves.
In addition to this, a sex positive world would
be more poly-positive as the number of partners
and their genders would no longer be of importance
as long as everyone is happy. Glickman demonstrates
how becoming sex positive helps bring the world
closer. Another advantage of sex positivity as stated
by the author is that it helps us get what we want
by doing the equivalent of trying new foods. It
hence accommodates for the fact that our sexuality
changes over time as a result of which our needs
change too.
Sex positivity also changes the
way we speak in several ways. The author brilliantly
describes how language around sex reinforces sex
negativity without our realizing it. He explains
how while abusing people we use words that are sex
related such as asshole, dick etc. as opposed to
calling people elbows or ears! This clearly demonstrates
that some part of us believes that there is something
wrong or bad about these organs. Trying to use other
words can thus change how we think about sex words.
Another change in language as a result of sex positvity
is being able to use accurate words and hence being
able to convey what one really wants. Also as Glickman
illustrates, since most of our sex negativity comes
from our body negativity, overcoming one often involves
overcoming the other. In addition to this, Glickman
explains how learning to break sex negativity is
linked to working to end other prejudices. An example
provided by him to illustrate this point is how
sex negativity enforces sexism every time a woman
is insulted by being called a slut.
The author succeeds in conveying
to the readers the importance and need for sex positivity.
In today’s so-called liberated culture, it is indeed
sad that we are still unable to come to terms with
our sexuality and to accept sex for what it is-a
basic need for every human being. We still view
sex as being an animalistic instinct that is necessarily
evil unless it is used for procreation, especially
in India. It is necessary for us to break these
barriers of sex negativity in order to be able to
function at an optimum level in various domains
in life. Articles |
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such as the one by Glickman can
go a long way in changing negative attitudes about
sex. In addition to being compelling and forceful
this article in itself succeeds in breaking the
first barrier of sex negativity by openly talking
about sex and the need for sex positivity. Moreover,
the article helps us understand how many prejudices
just creating a more sex positive world can do away
with. Just imagine how much more tolerant we would
be of the gay and lesbian communities if we were
sex positive. And this covers only one domain of
discrimination. We can only imagine how many more
forms of prejudices a sex positive world can get
rid of. Food for thought, isn’t it!
Readers can find Charlie Glickman’s article in
the Electronic Journal of Human Sexuality, Volume
3, July 6, 2000 at www.ejhs.org
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Father: The shock treatment
did not help cure my son’s illness.
But it saved me a lot of money otherwise.
Friend: How?
Father: I bought only one
movie CD for him to watch. He has already
watched it 40 times. But everytime he
watches it, he thoroughly enjoys it,
as if it was the first time he is seeing
it. He doesn’t remember anything! |
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The workshop on "The Family and
Mental Health", organized by Anveshi, Hyderabad in
April 2003, was the outcome of the year-long discussions
within the Study Group on Mental Health in Anveshi. In
the study group, several issues relating to the understanding
of and coping with distress were debated in the context
of the family. These debates highlighted the fact that
what each of us understand as the family was necessarily
different – a difference that is not simply in terms of
an ahistorical experience of the family, but rooted in
the changing modes in which the idea of the family was
being articulated. The workshop sought to look closely
at the articulations of and negotiations with mental distress
in the context of family and addressed concerns in understanding
distress, the question of care, issues in working with
families and the legal implication for the family as caregiver.
The introduction by Jayasree Kalathil
(Anveshi, Hyderabad) laid out how the family features
in statist interventions and policies on mental health,
the concerns that have come up in discussions within caregivers’
groups and as spoken about in narratives of distress.
In statist interventions and policies, the family is mostly
seen as an isolated unit, with a natural tendency to nurture.
There seems to be little acknowledgement of the conflicts
within families and the contradictory desires of individual
family members. These are evident in the concerns of caregivers
groups and in the way distress is articulated in experiential
narratives. The isolation that the family faces in mental
health care seems to be the result of a lack of understanding
of the family as a complex unit within political processes.
The significance of mental distress and the experiences
of it need to be placed within institutions, language,
interactions and discourse for a more nuanced engagement.
Reviewing the social anthropological
engagements with the family, Bindulakshmi (IIT, Mumbai)
elaborated on the problems with understanding the family
as the ultimate location of care. Despite efforts to universalize
and naturalize the heterosexual family, there is more
and more evidence of crisis within family. What is required
is a re-articulation of individual emotions. We need to
consider that emotions are not only the products of socialization
but might also break away from given patterns of social
mandates, within which they are sought to be authorized
and expressed. It is only through a concerted and systematic
dismantling of the existing ideas of the family, familialism,
family ties and familial emotions that we can arrive at
a positive articulation of emotions, thus paving the way
for a better and healthy living standard for the individual
within this institution.
Is a re-examination of the family as
an institution necessary in the context of mental health?
Is it not enough to address how each individual member
reacts to distress within the family? It was felt that
while individual interactions with the distressed person
is extremely important– and is the most commonly addressed
issue in family therapy– it is the absence of a critical
analysis of the idea of the family that creates the current
situation in concerns about the family in mental health.
In addition, how much can a therapist do to negotiate
individual interactions?
Sadhana Vohra (The Psychological Foundation,
Delhi) looked at how the therapist negotiates with the
family. The issue of "my family" and "what
they have done to me" seems one of the main things
that many people have had to deal with in their work on
their mental health. Very often, a family’s concern is
experienced as controlling and leads to many of the tensions
in the relationship. The idea of "toxic families,"
where the structure works in modes of controlling and
containing, is still valid. A therapist’s work is to help
identify support and separate it from control and to facilitate
the client to work with the support to enhance her mental
health. The need to question assumptions about unconditional
love was raised again by Sadhana, even as she spoke of
the shifts in the rigidities associated with the Indian
family. |
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Looking at the representations of mental
health and the family in Hindi cinema, Madhumeeta Sinha
(Anveshi, Hyderabad) spoke of the conspicuous absence
of the family in recent films like Road, Deewangi
and Aankhein. In a context where the family is
often the site of conflict resolution in Hindi cinema,
the absence of any discussion of the family in these films
lends to the construction of the obsessed individual who
pushes his desires to limits without being concerned of
the consequences. Another break with the past is the portrayal
of the villainous heroes in these films in a way that
invokes the sympathy of the audience. The narratives in
these films seem to blur the boundaries between sanity
and insanity and between being good and being bad. We
need to explore the consequences of the absent family
in the portrayal of cinematically defined mental illness.
Another context where the family often
finds itself in a fraught situation is the legal aspects
of mental health. Analyzing the law’s interest in mental
health, Amita Dhanda (NALSAR, Hyderabad) said that along
with its concern of preservation of order, the law is
also concerned with protecting people in distress. In
almost all instances, the legal provisions are activated
not by the people for whose protection the law claims
to function but by people who benefit from their property.
The legal order battles with the question of the family
as protector and as transgressor. As protector, the law
designates the family as the surrogate decision- maker
for the person with mental illness and empowers it to
take all kinds of decisions relating to care and treatment.
As in other contexts, in the legal context also, there
is an assumption of the innate good intentions of the
family towards the person experiencing mental distress.
It assumes that relatives cannot or will not treat this
person cruelly. But even as these assumptions are made,
the law recognizes the family as transgressor. For instance,
no legal heir can be appointed as a surrogate decision-maker.
This is a major acknowledgement of self-interest or conflict
within the family. The law essentializes both the family
and the person with mental illness. There is no recognition
of the nuances of either the family or of mental illness.
While there seems to be some suspicion in matters regarding
property, there is no such acknowledgement in matters
like personal liberty of the person with mental illness.
The nuances of the negotiations that
go on in the situation of family based care were discussed
in the panel on "Questions of Care." K. Lalita,
Sheela Prasad, Veena Shatrugna and Vasudha N (Anveshi,
Hyderabad) spoke on the panel. Based on interviews with
two persons diagnosed with schizophrenia and their families,
Lalita and Sheela spoke of many issues in care. In general,
they found that psychiatrists are more concerned with
diagnosis and cure rather than involving the family in
care. There is very little help for the family members
from any quarter. They have to deal with their sense of
guilt, shame and often their own stress and depression
on their own. Social ties are slowly lost and they seem
to move towards larger isolation. Each family seems to
work out their own ways of dealing with everyday life,
taking care of the needs and communicating with the person
experiencing distress.
Veena’s presentation reiterated the social
isolation and "shrinking" that the family experiences.
She raised the question that perhaps family is not the
best place for care. It is the family that is the most
involved; it is also the one that is caught in the complicated
patterns of communication. We have only frightening histories
of mental hospitals. The only available resort for the
families are the dargas, babas and so on. It is unfortunate
that we did not work with any other system that gave the
right amount of care, love and perhaps medication. The
family is fairly burdened and the stress placed on it
produces all kinds of skewed reactions. We need to do
a lot more work in this area in order to find out how
to open up new spaces within the structures of these institutions. |
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Vasudha felt that the idea of care in
the context of mental distress is very different from
that of physical illness. One has no physical measures
to depend on to gauge the reactions of the person one
is caring for. Vasudha also pointed out that the kind
of care that is required is very specific to the person
who is being cared for. For instance, caring for a child
who is experiencing distress is very different from caring
for an adult. The world of the caregiver is as isolated
as that of the person experiencing distress. Rather than
posing them as in opposition with each other, we need
to understand how they are trying to work out a world
together.
The workshop raised several issues about
the family in mental health care. On the one hand, it
was felt that in the absence of any other unit which is
involved in care, the idea of the family needs to be retained
unquestioned. Negotiations happen in these spaces and
the person’s stature in the family changes over time,
resulting in changes in the ways in which the family reacts
to the person’s distress. On the other hand, several people
argued that the ahistorical and isolated ways in which
the family or members of the family continue to exist
in the thinking about mental health care perpetuates the
completely individualized understanding of distress itself.
Everything becomes a matter of personality, as if personality
itself is a natural category. Unless we take into consideration
the ideological baggage that overwhelms the disparate
ways in which families actually function in society, can
there be any way out of the static and individualized
idea of the family and of distress, not only in therapeutic
situations, but in the larger contexts of mental health
debates.
Is the problem, then, with the assumed
naturalness of the space of the family as the only space
where an individual really belongs? Is "the family"
that we are talking about the same as "the family"
in social anthropology or in feminist criticism? Or would
it be more productive, for mental health debates, to look
at the negotiations that happen within spaces of care,
and see what idea of the family emerges from these negotiations?
The workshop opened up several questions for future work
in this area.
Jayasree Kalathil prepared the report
for the Study Group on Mental Health, Anveshi Research
Center for Women’s studies, Hyderabad
(hyd1_anveshi@sancharnet.in). Jayasree started
the aaina initiative in 1999 for Bapu Trust. She now
works with the Mental Health Media, London on an anti-discrimination
tool kit project for users of mental health services.
She can be contacted at- jayakalathil @yahoo.com
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Thank you, aaina readers,
for your feedback…
Of the 200 letters sent out to
readers of aaina, we received 26 valuable
responses. You have found aaina useful. Some
feel that clinical aspects of mental disorder should
be more comprehensively covered, but others feel
that aaina is set at the right, if unusual,
pitch. You have given a wide range of topics for
more comprehensive coverage, including
"Mental health of women,
homeless people, people within institutions, positive
mental health, prevention, latest drugs, new research,
ethical issues in mental health, emerging psychiatric
illnesses (ADHD and PTSD), more on Drug Tracks,
role of the family, linking with disability rights,
suicide prevention, user accounts of drug use,
more of advocacy news and speaking our minds,
rural outreach, human rights, news about voluntary
organisations, use of art forms in overcoming
trauma, yoga / meditation in mental health, rehabilitation,
stress management and policy.
You have urged that we do less armchair, and more
action oriented, writing. This sharing has helped
us to imagine an aaina community, and we
hope to draw from your vision and experience to
take aaina forward in the coming months.
Do write in about concerns, initiatives and campaigns
from your own region. |
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Rose D, Fleischmann P, Wykes
T, Leese M, Bindman J. (2003) Patients’ perspectives
on electro-convulsive therapy: Systematic review.
British Medical Journal, June 21, Vol 326:
p. 1363
The objective of this systematic
review was to ascertain patients’ views on the benefits
of and possible memory loss from electroconvulsive
therapy, by looking at data sources from Psychinfo,
Medline, Web of Science, Social Science Citation
Index databases, and bibliographies. Articles with
patients’ views after treatment with electroconvulsive
therapy were selected. 26 studies carried out by
clinicians and nine reports of work undertaken by
patients or with the collaboration of patients were
identified. 16 studies investigated the perceived
benefit of electroconvulsive therapy and seven met
criteria for investigating memory loss. The review
shows that the methods used by the studies were
associated with levels of perceived benefit. At
least one third of patients reported persistent
memory loss. The study concluded that the current
professional claim that over 80% of patients are
satisfied with electroconvulsive therapy and that
memory loss is not clinically important, is unfounded.
Bolton P, Bass J, Neugebauer
R, Verdeli H, Clougherty KF, Wickramaratne P,
Speelman L, Ndogoni L, Weissman M. (2003) "Group
interpersonal psychotherapy for depression in
rural Uganda: a randomized controlled trial"
Journal of the American Medical Association,
June 18, 289(23): pp. 3117-24.
The objective of the study was
to test the efficacy of group interpersonal psychotherapy
in alleviating depression and dysfunction and to
evaluate the feasibility of conducting controlled
trials in Africa. For this cluster randomized, controlled
clinical trial, 30 villages in the Masaka and Rakai
districts of rural Uganda were selected. 15 were
then randomly assigned for studying men and 15 for
women. In each village, adult men or women believed
by themselves and other villagers to have depression-like
illness were interviewed using locally adapted |
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tools. 341 men and women who met
Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV) criteria for major depression
or subsyndromal depression were interviewed. Of
these a total of 108 men and 116 women completed
the study. Eight of the 15 male villages and 7 of
the 15 female villages were randomly assigned to
the intervention arm and the remainder to the control
arm. The intervention villages received group interpersonal
psychotherapy for depression as weekly 90-minute
sessions for 16 weeks. Main outcome indicators were
reduction of depression and disability. The study
found that group interpersonal psychotherapy was
highly efficacious in reducing depression and dysfunction.
This is a benchmark study in appropriate cultural
psychotherapeutic models for use in depression care
in non-western societies.
Laine, K., Heikkinen, T., Ekblad,
U. and Kero, P. (2003) "Effects of exposure
to selective serotonin reuptake inhibitors during
pregnancy on serotonergic symptoms in newborns
and cord blood monoamine and prolactin concentrations"
Archives of General Psychiatry, July, 60(7):
pp. 720-726.
The study investigated the perinatal
sequelae of infants exposed to SSRIs during their
fetal life and the relationship of these symptoms
to the cord blood monoamine and prolactin concentrations.
It was a prospective, controlled, follow-up study
with 20 mothers taking 20 to 40 mg / d of either
citalopram or fluoxetine for depression or panic
disorder, and their infants, and 20 matched controls
not receiving psychotropic medication for confounding
obstetric characteristics. Maternal cord blood and
infant drug concentrations were measured. The newborns
underwent standard clinical examination and specific
assessment of serotonergic symptoms during the first
4 days of life and at the ages of 2 weeks and 2
months. The study found that infants exposed to
SSRIs during late pregnancy are at increased risk
for adverse effects on the serotonergic central
nervous system. |
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summer placement as a first year student of NALSAR,
University of Law, Hyderabad, was at the Central
Institute of Psychiatry (CIP) in Ranchi from the
10th
of May, 2003 to the 30th
of May, 2003. As part of my placement, I interacted
with the doctors, nurses as well as the patients
with a view to gain a first-hand experience of the
state of institutionalized care for the psychiatrically
challenged and analyze the role of law and its effectiveness
in this field. The more time I spent working at
the CIP, the more I realized that the need for proper
legislation for the protection of the mentally challenged
against discrimination and exploitation is immense.
Medical disorder is an illness
as well as a disability. Like any other human being,
the people with mental disorders too have rights.
But because of their disability they are more prone
to discrimination and exploitation. That is where
law is required to safeguard their interests and
rights, and for the welfare of the mentally disabled.
The time at the CIP was well spent,
gathering information about the admission procedures,
kinds of ‘illness’, forms of treatment, a study
of outpatients vis-à-vis the inpatients, facilities
provided in the hospital premises, etc. During my
assignment, I realized that there were working problems
that created loopholes in the provisions of the
Mental Health Act, 1987, to the detriment of the
mentally ill patients at large. The ground realities
and practicalities (at least with regards to the
CIP) make it difficult to implement the provisions
in the spirit they were intended to be.
The Central Institute
of Psychiatry was established on the 17th
of May, 1918. Initially, it catered to the needs
of European patients only. Eighty five years down
the line, it is one of the premiere psychiatric
institutes with the best facilities and doctors
in the country. It runs under the administrative
control of the Directorate General of Health Services
under the Ministry of Health and Family Welfare,
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The Institute covers a sprawling
400 acres of land with an immense scope for development.
The Outpatient Department (OPD)
functions in a separate building outside the main
hospital boundaries of the CIP. The number of patients
from various parts of East India who are treated
at the OPD has been steadily increasing. In 1980,
only around two thousand patients came for consultation
services and most of them got admitted. Twenty three
years later, the OPD of the CIP now gives consultation
to more than twenty five thousand patients a year,
few of whom are admitted. The OPD also has wards
to admit patients temporarily or in cases of emergency,
when admission to the in-patient department is not
possible. Electro convulsive Therapy (ECT) is available
in the OPD. The doctors here examine the patients
and determine whether admission in the IPD is necessary.
Patients requiring consta | | | |