After decades of consultations, putting pressure on the government, advocacy and activism, the Mental Healthcare Bill finally came down to a six hour long discussion, before it was passed by the Lok Sabha on March 27. It’s aim – to provide, promote and fulfil the rights of persons with mental illnesses.
The bill repeals the existing Mental Health Act of 1987, which had been widely criticised for not recognising the agency and capacity of a person suffering from a mental illness, and which like many legislations around the world, was drafted to safeguard the public from ‘dangerous patients’ by simply isolating them.
As someone who has worked in the mental health sector, focussing on busting stigma and spreading awareness, it gives me great relief to know that we have finally done away with a legislation that not only promoted human rights violations, but also looked at an entire section of society as “incapable” of making decisions for themselves.
As much of a good news the passing of this bill is, there are still some aspects of it that call for concern.
While on the one hand, the Advanced Directive gives complete freedom to a person diagnosed with a mental illness to decide the course of action for his/her treatment, it does leave room for this same directive to be questioned, changed and/or be completely ignored.
Jayna Kothari, a human rights lawyer and co-founder of the Centre for Law and Policy Research shares her view on this.
Jayna Kothari, Humar Right LawyerRevoking the Advanced Directive by a professional, caregiver or family member does undermine the autonomy of a person with mental illness. If we really want implementation to be done in the right spirit, the Mental Health Board should be constituted well. It is important to ensure that they not only have the right experience, but are also sensitive to rights of those with mental illness.
In a country like India, where doctors are almost always taken at face value and people surrender themselves and their families to their mercy, most Psychiatrists like the rest of the medical fraternity, are used to deciding ‘for the patients’.
The Mental Healthcare Bill seems almost too progressive and unrealistic for a lot of doctors, who are simply not used to viewing patient care under this lens, because they have been used to being the sole decision makers for those with mental illnesses.
This is especially true in low income families, from smaller towns and villages, where the ratio of mental health care services to those who need this care is so skewed, that it becomes a huge burden on the limited number of centres. Hence, the quality of care given is heavily compromised. This in turn leaves a majority of the population undiagnosed and untreated.
Dr PV Bhandary, Medical Director and Psychiatrist at Baliga Memorial Hospital in Udupi, shares the pros and cons of the bill.
Dr PV Bhandary, Medical Director and Psychiatrist at Baliga Memorial Hospital, UdupiDecriminalisation of suicide and emphasis on community based care are definitely positive signs. The bill will also hopefully stop ‘good samaritans’ from going around and rescuing people from the road, institutionalising them without their consent and sharing their images over social media and WhatsApp. On the flip side, if someone does not have insights into his/her illness and is brought by a relative, this bill gives them the power to refuse admission. This case is then presented to the Mental Health Review Board, a team of six members that comprise of - a psychiatrist, social workers, caregivers and persons living with mental illnesses. Situations can arise when the psychiatrist/family members do not agree with the decision of the board, which will then be taken to court. An already loaded judiciary, will start interfering in cases of mental illness.
In order for the Advanced Directive to play out like it should, shouldn't all of us start educating ourselves about the various treatment options available and outline our choices to be prepared in the future, if we do get diagnosed with a mental illness? This brings me to extreme treatments such as Electroconvulsive Therapy.
Forceful sterilisation of girls and women has plagued India for decades now and this ban by the Bill is a positive step towards ensuring their reproductive rights are not violated. It will be important to ensure that hospitals implement this and are not subjecting the patients to abuse, which is most cases has either gone completely unnoticed or unreported.
The Mental Healthcare Bill’s stand on Electroconvulsive Therapy (shock treatment) has raked in varied opinions. Historically, ECTs have been one of the most controversial treatments in medicine and its portrayal has been polarised, skewing only towards its negative effects. This has made many vary of this form of treatment. Anoopa Anand, a woman living with a mental illness, recently published her take on ECTs specifically.
Anoopa Anand, Writer, editor, and animal welfare workerWhile we are celebrating the ban on ECT for minors, the bill merely limits its use for adults: a shockingly regressive move. Everything we know about ECT points to the ‘zombie-like’ vegetative states that it results in. If experts in the field can effectively conclude mental illness from the grossly distorted glass of pathology, what this vegetative state further proves is the existence of fallback on such malnourished theory. Little attention is then required to be paid to whether or not the pathologies were a result of ECT or existed before such therapy was performed.
I take a slightly different stand on this. Studies on the use of ECTs, their advantages, disadvantages and the ways in which they can be administered without causing harm and with informed consent, have been inadequate in India.
How then can we already assume that it is a “regressive move”? If we are speaking a language of ‘choice’ with this bill, then ECTs too, just like other forms of treatment, are still a choice, until proven otherwise.
Rohan Sabharwal, a filmmaker who has been living with bipolar disorder for nearly two decades, shares his experience with ECTs-
Rohan Sabharwal, Filmmaker and Mental Health activistA year and half back (when I was suicidal) if you asked me about ECT and what I thought of it, I was against it. But today, I think it is one of the reasons I am alive and able to function the way I am. In countries like the US, it is treated as one of the many options of treatment. While I definitely do not advocate ECT without consent, I feel that we are losing the plot by demonising it and adding to the portrayal of it turning people into “zombie-like” vegetative states, which is not the correct and complete picture. Yes, regulating it is necessary, but I do not think we have established a balanced argument for and against it, to even discuss doing away with it altogether.
The Department of Psychiatry in Christian Medical College, Vellore conducted a study titled that outlines both positive and negative responses and perceptions of people who have received ECT. While this study has not been able to ascertain whether or not ECTs should be banned, it does outline a holistic approach, that ensures a basic minimum standard to obtain informed consent and suggestions to improve ECT practices in India.
I couldn’t agree more with Shashi Tharoor when he said in the Lok Sabha that law enforcement agencies and first responders in incidents of suicide must be sensitised. He also urges the Union Minister of Health and Family Welfare to look into the caseload of those locked up involuntarily. Clearly, the passing of the Mental Healthcare Bill is only the first step. As far as the infrastructure of mental healthcare in India is concerned, we still have a long way to go.
According to WHO data, there are three psychiatrists per million people, in India, which is 18 times lesser than the Commonwealth norm of 5.6 psychiatrists per one lakh people. India only spends 0.06% of its entire health budget on mental health. How will 4,000 psychiatrists, 1,000 psychologists and just 3,000 social workers suffice, when more than 5% of our population is living with a mental illness? How do we ensure that 70% of India’s rural population actually gets access to mental healthcare?
The Mental Healthcare Bill has the potential to turn things around and each one of us has a role to play in its implementation.
Dr Vikram Patel, a pioneering psychiatrist in community based mental healthcare The passage of the Mental Healthcare Bill by the Lok Sabha is a momentous milestone in the struggle for the realisation of the rights of people with mental health problems in India, to a life with dignity and access to community based care. Now, the responsibility falls upon all concerned sectors in the government, health professional communities and civil society, to join hands towards converting the high ideals of the bill into reality.
(Rachana Iyer is a writer, social impact specialist and co founder at CraYon Impact, an enterprise that produces content, events and campaigns around issues of Disability, Mental Health and Gender. She is an alumna of The Centre for Disability Studies from the Tata Institute of Social Sciences, Mumbai.)
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