Behind Stone Walls and Iron Doors

Editorial note: Through personal observations of the author who has spent time working at a large government-run hospital in India, this article looks at the Indian Mental Healthcare Act and brings out its implications and challenges. The window into reality that the author’s experience offers argues how things are one way on paper, but another way on the ground. While Mad in Asia Pacific does not endorse the biomedical model, it is important to call out practices and issues prevalent in such resources, which are, in fact, offered to the public at large in the name of mental health care. The observations presented here should also lead us to consider the larger issues of dehumanisation, institutional damage, iatrogenic harm and societal apathy embedded in colonial-era systems such as this so that we can all work towards systemic change.

The Mental Health Care Act was passed by the Indian Parliament on 7th April 2017 to provide mental health care and services to society and to ‘protect, promote and fulfil’ the rights of people during the delivery of such services. This act was considered a big step towards mental health awareness as a much-needed revision of the antiquated Mental Health Care Act of 1987. The Act of 1987 was regressive on many fronts and the current revision brought some positive changes. For instance, it decriminalised attempted suicide, restricted the use of ECT (electroconvulsive therapy), increased community participation for mental health awareness and also aimed to reduce the stigma and discrimination around mental health.

One ambitious clause of the Act talks about providing infrastructural resources for safeguarding the rights of persons in need of mental health services, upholding their right to dignity and personal contact, to relevant information, to confidentiality, to legal aid, and so on. The Government has undertaken the responsibility of providing facilities like halfway homes, shelter facilities, rehabilitation centres and mental health institutions. This may seem like an optimistic endeavour; however, the ground reality is different and the provisions are not being implemented thoroughly. The best illustration of this would be the present conditions at India’s government mental health institutions.

Currently, India has about 43 government mental health institutions across different states. Mumbai, one of the biggest and most populous cities of the country, unfortunately, has only one, situated in Thane district – the Thane Regional Mental Hospital (TRMH). This means that the bulk of the responsibility of the mental health needs of 1.84 crore people is shouldered by a single government mental health institution. There are, of course, private institutions providing psychological and psychiatric services, but only to a small population. In a developing country like ours, the socio-economic divide restricts people from the lower strata from availing services from private health institutions. During the course of my work as a clinical psychology intern at the Thane mental health hospital, I observed that the people coming to the hospital were mostly from the middle and lower-middle classes and were generally unaware of the importance of mental health and related services.

Overburdening (too few doctors and too many patients) and lack of awareness among people have given rise to problems like scarce infrastructural resources, poor quality of psychological and psychiatric services, very few mental health professionals, and overcrowding in the hospital. The hospital, sprawling over 76 acres of land, is experiencing pressure from both inside and outside the institution. The state-run facility is located in the heart of Thane, and the state government has already sanctioned the use of 14 acres of its land for building a railway station. Losing this much land may restrict the freedom and autonomy of over 1200 inpatients who use their free time to walk in the greens, attend occupational therapy which includes physical exercise, games and other recreational activities.

Much of my work was with inpatients in the wards, and the condition of the wards shocked me. The 30 wards were divided into five sections, with male and female wards separated from each other. The institution is not inclusive towards others who do not fit into this gender binary. Today, the mental health community is striving towards achieving an inclusive approach, yet this age-old institution has turned a blind eye towards repeated calls for inclusion from various groups.

The structure of the hospital is not welcoming either. One cannot fail to notice the chipping paint, damp walls and unclean floors: the dark and gloomy atmosphere only reinforces the stereotypes and stigma surrounding mental health hospitals, though the administrative staff tries its best to provide a safe and sanitised environment with the scarce funds and resources. The inpatients of a ward shared a common corridor with a single washroom, and they were supposed to spend most of their days together. The entrances to the wards were made of big iron bars that made the wards look like prison cells. Such an inhumane arrangement compromises their sense of privacy and access to personal space. Once, while I was conducting an assessment with an inpatient in a male ward, I was shocked to discover that the ward was shared by both TB (tuberculosis) and non-TB patients, with a single stool serving as a partition between the two. Worse still, the staff of the ward had not cautioned me about this until the inpatient himself informed me. This lack of hygiene and sanitation increases the risk of non-TB patients contracting the disease and is, of course, an alarming concern in these stressful times of the COVID-19 pandemic. Two patients and one staff member here have already succumbed to the virus whereas 17 patients and 22 staffers have contracted it.

Demonstrating the understaffing and overcrowding at the institution, only six psychiatrists attend to 1360 inpatients and also run the OPD (out-patient department) where more than 300 clients come to seek help daily. According to the authorities, they have allotted vacancies for ten doctors; however, four posts remain unfilled. This poor doctor-patient ratio also influences the course of therapy and rehabilitation. The nurses in the wards informed me that the doctors cannot check in with all patients every day. Even among those who are attended to, the doctors cannot spend more than ten minutes with each of them. In a field where active listening and rapport-building should form the basis of the client-therapist relationship, the inpatients of the facility are being denied their basic rights as clients.

The situation is similar when it comes to clinical psychologists: the hospital has had vacancies for the posts of clinical psychologists to conduct psychological assessments and offer therapy for many years now. Although there are occupational therapists and some rehabilitation activities are conducted, many clients are either misdiagnosed or not diagnosed at all, due to the lack of clinical expertise. Nonetheless, the hospital allows for internship opportunities for post-graduate and M.Phil. students of clinical psychology, who conduct assessments and therapy with clients.

Since the last few years, a new trend in the admission of clients has been observed at the facility. The hospital has limited its intake policy and focuses more on OPD clients. This is being done to reduce the overcrowding in the wards, which has increased considerably over the last few years. According to a February 2020 report, the state of Maharashtra has the highest number of long term patients in government mental health hospitals. In order to deal with the situation, many hospitals try to rehabilitate the inpatients by placing them in halfway homes and rehabilitation centres. As if living in a mental health hospital in such inhuman conditions were not traumatising enough, many of those fit to be discharged are being sent to dilapidated beggar’s homes in the name of rehabilitation.

One reason for this gross mismanagement is that even though many inpatients are discharged officially, their family members do not take them home, thus lengthening their stay at the hospital. Many inpatients personally asked me to put in a good word with the officials so that they could go back home, but I did not have the heart to tell them that their families may not want them back. The patients eagerly wait for their discharge date so that they can finally be together with their families, however, the deep-rooted stigmatisation of mental health problems keeps the families from taking their loved ones back. They shun their mentally disturbed relatives either of their own accord or to save themselves from the embarrassment that is caused socially. Though the complicity of families is jarring, one cannot completely blame them because their views on mental health are a byproduct of how these mental health hospitals are run. Given a safe and sensitive environment, persons with mental disturbances would not only thrive but their families would also be empathetic and responsive towards their needs.

The families’ postponement or refusal to take their relatives back home reflects a lack of understanding and acceptance of mental health concerns that I believe is at the core of many issues discussed above. The attempts to encroach the hospital land indicates the insensitive attitude of authorities towards mental health care. The under-staffing and overstretched resources reflect the unwillingness of the state to take notice of the gravity of the situation. The situation at Thane regional hospital is much worse than that of three other mental health hospitals that exist in Maharashtra, although they are facing issues of their own.

In today’s times when mental health awareness and advocacy are at their peak, it is astonishing to see mental health facilities in such a poor state. The mental health community has come a long way in their sustained resistance to the biomedical model of mental health by focussing on the psychosocial aspects of mental distress. It is now only fair to take this conversation out in the field and implement it in our mental health facilities as well. It will take some time, but the community has collectively started taking first steps towards achieving the goal of safe, inclusive and client-centred mental health facilities by openly discussing mental health, and thus attempting to reduce the stigma attached with it. And one day, we might even do away with the very concept of a ‘mental hospital’ and all those trapped in there will fly over the cuckoo’s nest.

Madhureema Neglur: “If I had to describe myself in one line, I would say, “I’m Jack of many traits”. As a Mental health professional, I have a deep passion for mental health awareness as well as Japanese language, and dance. I am constantly striving to bring all three together under one roof and view them from the lens of psychology.”

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