A lot of our mental hospitals remain places of abuse and violence, prisons in effect. How can we humanise these institutions?
Many mental hospitals in India continue to be shadowy prisons for the forgotten and wretched. The human rights, humane care and rehabilitation of persons with mental illness is one of the darkest chapters of India's mixed record of enforcing human rights and ensuring healthcare for all. A survey some years back by the National Human Rights Commission, as well as several other independent reports, establish that people living with mental illness in mental hospitals frequently continue to be subjected to various forms of inhuman treatment, which are particularly unconscionable in the light of contemporary advances in medical knowledge.
Patients in many hospitals are found to suffer brutal treatment, violence, abuse, or neglect at the hands of untrained medical, nursing and orderly staff. There is excessive regimentalisation, and a regime of fear, and opacity. Chaining or other barriers to free movement even within the campus of the institutions was common even a few years ago, and has not fully disappeared. In some hospitals, patients are denied most basic facilities such as clothes, beds, clean toilets, and regular bathing. As in all institutions, there is often corruption in the purchase and management of food and other consumables, and food served is poor in nutrition, and badly cooked.
Inadequate medical facilities for ailments of the body, combined with abysmal living conditions, leads to illness and even tragic deaths of patients from entirely preventable non-psychiatric ailments. There are still reports of brutal and indiscriminate application of ECT, or the controversial application of electrical current, without anaesthesia. In many hospitals, patients can rarely meet their families, and several families abandon the patients. There is almost exclusive reliance on pharmacological remedies, with little or no psychotherapies, counselling, or alternative therapies. To make matters worse, there is little done to prepare the patients to resume life after discharge. Neither they nor their family members are counselled even about the imperative for regular medicines, even less are they prepared for the emotional stresses of re-integrating with their families, and resuming interrupted professions or educational careers. It is not surprising therefore that the patients who are discharged frequently return to the mental hospitals, for longer and longer periods, with less and less hope.
The interventions of committed professionals, organisations of patients and their families, civil society groups, judicial activism and the NHRC have initiated heartening reforms in many hospitals, in which patients are encouraged to stay for short periods with their families, and then get discharged. But within the walls of several mental hospitals, not enough has changed for people living with mental illness, especially those who are further disadvantaged because of gender, caste or poverty.
The most tragic predicament is of patients who are abandoned in the mental institutions, often with the active complicity of hospital staff. The members of the families of patients give false addresses, or fail to respond when hospital authorities write to them that they should take back home patients ready for discharge. As a result, in all mental hospitals, many patients, especially women, are abandoned for years, decades, even lifetimes. Senior staff in many hospitals has persisted with untenably labelling some patients as ‘chronic', ‘incurable', ‘burnt-out' and requiring lifelong custodialisation. Medical science today does not justify writing off the future of any patient.
Compassionate mental health professionals like R. Srinivasa Murthy stress that the long-term answer to all these problems is to break down the walls of institutions, to end medical legal and social practices which sanction the custodialisation and brutal treatment, neglect or abandonment of people living with mental illness. Murthy believes that treatment of new patients of mental illness, and new episodes of mental illness must be integrated in primary healthcare, with referrals to secondary and tertiary levels in units or departments of district and medical college hospitals. Such de-stigmatised care must encourage the participation of families and other care-givers, build their capacities and those of patients themselves, provide them ongoing support, and give services that extend well beyond pharmacological care of people living with mental illness.
To prevent new prison-like institutions, no new custodial institutions for people living with mental illness should be permitted to come up. Only out-patient care and wards in mainstream hospitals and clinics should be available for largely voluntary admissions by patients of mental illness, their family members or friends. At the same time, in existing mental hospitals, the first step should be the creation of team of social workers to work intensively for the care and rehabilitation of patients and humanising of the institutions. These teams should comprise a core of clinical psychologists or psychiatric social workers, but, for the rest, should comprise lay, whole-time volunteers and workers who are selected for suitability of temperament, motivation and commitment, and are intensively trained. The team should also seek volunteers from among the staff of the mental hospital itself, who wish to participate in the processes of humanising and de-institutionalising mental hospitals.
This is the approach of organisations like Anjali in Kolkata, and the results have been very encouraging. The regular entry of social workers has been found to create an atmosphere of transparency which mitigates some of the worst excesses of an institution. The team works directly with patients, preparing them for re-integration with families and work after discharge. They also work closely with family members, extending support and counselling, and encouraging them to take care and give fair life chances to people living with mental illness in their families. Both patients and family members are trained about the importance of sustaining regular medication, and other precautions to prevent relapse and early detection when problems arise. Anjali initially demarcates areas within the campus of the institutions for alternative care of patients who are being prepared for discharge, and for active participation of family members. However, eventually the entire character of the hospital itself should be transformed. Into open, therapeutic, non-custodial, rehabilitative, humane centres for services and care of people living with mental illness.
A large majority of patients would be satisfactorily rehabilitated with their families and the community, through these methods. However, there will remain a core of patients who are wantonly abandoned by their family members; homeless persons with mental illness whose families cannot be traced; and people living with mental illness, who have dysfunctional, abusive families which are not compatible with the sustained recovery and human rights of the patients.
For this small core of patients, a lifetime without love and care behind the high walls of institutions should not be the path that is open to them. Instead, social workers should actively build alternative foster family situations, in which groups of around approximately eight such patients live as a family with a care-giver (a woman, man or couple) in homes in the open community. The Banyan in Chennai has experimented with a ‘protected community' of such foster homes, for women who live with severe mental illness and have no families to return to. This village is one in which these women find new bonds of family and friendship, and they move freely in the community, where they are accepted, given employment, and find respect.
Mental hospitals cater to less than one per cent of patients of mental illness. Therefore humanising these institutions must occur within a much larger process of integrating mental healthcare at all levels of public health care — primary, secondary and tertiary. It is only such a combination of interventions that can lead eventually to the restoration of the human rights of persons who suffer today from perhaps the most grave violations.
No person who lives with mental illness should be exiled from dignity. And, indeed, from hope.