#WhatWENeed - Inclusive Approach to Mental Health

Blog contributed by: Kavita Nair

Bapu Trust For Research on Mind & Discourse, Pune

Punitive? Biomedical? Recovery Based? Development Based?

What is the most appropriate System For Mental Health ‘Care/Treatment/Support’

A system which Criminalises Mental Health- where people with mental health issues are put into Custodial Institutions, have to go through Court Processes, are put into care of the state, Institutions- as a response to someone who is in distress? Where people with mental health issues are segregated through special laws.

Or

Medicalizing Human Behaviour - A diagnosis for everyone? Hospice Care? Pharmacotherapies? A biomedical system which dissects all human behaviour and responses under various labels- if responses are not fitting into being ‘acceptable and normal’. What maybe normal to one may be abnormal to another. Who decides what is normal? Where is the scope for people to express their distress without falling into the abyss of labels? Where is context of distress located within the disorder approach?

Or

Disability Perspective- Inclusive Societies? Rights based approach, Removal of barriers to growth?  Ecosystem approach? Locating the source of distress outside of the person, in the persons’ ecosystem. Engaging with various players in the persons circle of care to address barriers- stigma, violence, exclusion. Going beyond just survival of the person to facilitating conditions in which a person can thrive. To believe in evolving capacities of people. To consider opportunities on equal basis with others. To experience what it means to live a life of self-determination and dignity.

Persons with psychosocial disabilities across the globe, users, survivor groups, people who are labelled, diagnosed, people categorized as having mental disorders, people who identify with mad identities, are united in their identities as persons first.

The dominant narratives on mental health have moved, but little, in their focus from the medical model of disability as a functional analysis of the body, a machine to be fixed in order to conform with normative values. The focus on acknowledging and addressing the contributions of society in disabling people, stands a serious risk of dilution within the Global Mental Health Discourses in contemporary times. Voices from the GMH Movement continue to highlight the ‘Treatment Care Gap’ at a time and day when the need and demand for full compliance with the UNCRPD are being voiced strongly by persons with psychosocial disabilities themselves in low and middle income communities, the Global south, the Asia Pacific regions.

Presented here are concerns of a survivor, coming from personal experiences of violence, of trauma, of having seen peers, friends, colleagues incarcerated within repressive and oppressive systems of ‘what is considered as care and treatment approach!’

Persons with psychosocial disabilities are persons first, a fact that is often overlooked in the mental health sector. Special laws, acts, judicial processes, state institutions have been set up since the British era to ‘protect, treat and care for people with mental health issues.’ Voices and concerns of persons with psychosocial disability identities are close to absent in the making of these instruments that affect them directly.

When the India Mental Healthcare Act (IMHCA), 2017 came into force there was much celebration in the country from various stakeholder groups. The India Mental Healthcare Act (IMHCA), 2017 has the stated aim “to provide for mental healthcare and services for persons with mental illness and to protect, promote and fulfil the rights of such persons during delivery of mental healthcare and services and for matters connected therewith or incidental thereto.”

Seemingly a highly progressive piece of legislation, in theory. A closer look makes evident the vague, opaque language used in certain contentious areas; which represent arrangement-focused rather than realisation-focused legislation*, and can very well lead to inadvertent limitation of certain rights.

* Few points in consideration as examples:

• Mentions cessation of capacity, emergency treatments, power to MH professionals and caregivers to not follow the advance directive, protections to the medical practitioners on their liability for not following an advance directive 
• Capacity is defined as changing- talks about ‘having no capacity’ 
• The UN-CRPD appears strongly opposed to involuntary treatments and affirms the legal capacity of individuals at all times
• Mental illness is completely defined from medical standards- Act is for persons with mental illness. The power of diagnosing (labelling) rests in the hands of psychiatrists. Further, the justification to continue commitment to a person with mental illness in institutions is based on indicators of self-harm, harm to others, safety- continued biomedical framework of operation.
• Provides scope for ECT 
• Power is given to the local police to report incidences of ill-treatment and neglect of person with MI to a magistrate-but all actions following this actually has to do with assessment, treatment, commitment of the person and says nothing here about what needs to be done regarding the family/caregiver who is the perpetrator of this violence 

India ratified the UNCRPD in 2017, much before most other countries. A highly progressive legislation, the UNCRPD adopts a person centred, human rights approach to disability and sets the gold standards for persons with psychosocial disability to be able to be independent, to participate, to make choices, exercise autonomy, to contribute, to be fully included.

Unfortunately, the many local legislations set up for protections of persons with psychosocial disabilities do not directly/adequately address many of the areas of discrimination or social rights highlighted in the UN-CRPD or end up reinforcing/justifying rights violations in the name of care and protection. For instance, the IMHCA is at odds with the UNCRPD in many areas such as involuntary treatment, loss of capacity, emergency treatments, use of physical restraint and force, ECT to name a few. These directly conflict with the UN-CRPD.

The fact that there is a separate MH Act clearly demarcates from considering persons with mental health issues on equal basis with others. It is discriminatory, when there are no laws for people with diabetes, cancer, blood pressure and a host of other life long, serious or life-threatening conditions. Further it limits the opportunities for recovery to psychotropic treatments, hospitalizations, and custodial institutions.

There is no acceptance/recognition of the critical voices, research and evidence base in psychiatry on the severe and debilitating harms of long-term institutionalization, separation from families when taken away, traumatic effects of force, violence and coercion during incarceration, serious harm from drugs, loss of life itself- time, productivity, capacity to connect to others, to contribute in the entire process. Mental health and the need for addressing the treatment gap confers undue importance to the impairment rather than conditions which are leading to what people are experiencing as a response to trauma, abuse, serious deprivations. A pill cannot rectify a person’s environment to be less traumatic/abusive/deprived. Further it seems everything and everyone needs treatment- a completely reductionist approach to human life and conditions, ignoring causes and consequences framework of ill health and reflecting academic/medical arrogance.

Criminalising MH, issue of legal capacity, dangerousness and safety from people having mental illness, institutional systems to lock away people with mental health issues, isolating them keeping them away from the society through such measures, narrow biomedical (reductionist!) representation of persons suffering from mental illness, medicalizing communities in the name of capping the treatment gap, depicting them as ‘mad people’ who need to be treated, has resulted in generating stigma and fear on mental health issues and has led to exclusion.

There is a crying need to move from conservative, outdated, non-progressive approaches in mental health to embracing liberal, progressive legislations, systems, and responses, grounded in human rights, in the sector. To move beyond becoming alright, recovering to being fully included. This is possible only and only if we examine or responses, support, care systems through the UNCRPD framework, anything less than this is but a compromise.

How?

• Look at mental health from a disability perspective 
• Make it a development issue- looking at health determinants of mental ill health and addressing those- e.g. malnourishment, deficiencies and mental health problems, pregnancy and mental health
• Move from custodial nature of dealing with persons having mental illness to taking a proactive role of protecting rights of persons with psychosocial disabilities- change in language, in perspective, in attitude, in academic trainings provided in the mental health and disability sector, in mainstream education. Don’t medicalize communities, don’t drown community programs
• Recognise social determinants of mental ill-health and strategize to address them through existing systems- such as poverty alleviation program, ensuring food and housing for all, social security systems and benefits to marginalized groups, laws to protect vulnerable populations such as women and children from gender based discriminations, violence;      integrating holistic approaches in mental health care (active involvement of AYUSH), strengthening local communities through community building programs and teams (corporators, ward offices, local municipality, primary      health care centres etc); integrating mental health and wellness discourse in education systems at all levels, revisiting medical education curriculum on these aspects, having progressive discourses in mental health wellness, care and support in alignment with the UNCRPD etc
• Move beyond the narrow confines of defining it only through mental disorders- schizophrenia, depression, psychosis etc. MH is a spectrum. Every person has MH needs, different needs at different points of time, recognising this is most essential to escape the trappings of one’s identification being limited to presenting symptomatology! Not everybody      needs treatment! Not everything can be solved through treatment- Move away from bridging the treatment gap to bridging the UNCRPD gap
• Recognise the potential of harm and loss of life in pharmacotherapies. Recognise violations, violence by service providers, families when they force treatment. Shift focus from individual to ecosystem. Work on barriers to persons growth and development
• Asserting the right to personal choice: Be accepting of choices people make for themselves, whether someone want to heal through yoga or running or praying or learning from peers or whatever other ways they choose for themselves, it is their personal choice
• No incapacity laws, trusting the notion of evolving capacity- as applying universally.
• To be able to do all of this without pilling, without incarcerating persons, without use of force, without an overwhelming need for expert driven models of care and treatment. Transforming communities for inclusion. If this can be done, all people in that community will feel safe, cared, protected, nourished, respected, included.
• Do away with discriminatory laws, strengthen existing laws, systems in line with provisions in

• the UNCRPD 

When do I feel happy, safe?

What I have to say, what my peers have to say?

When do I feel respected, included, dignified?

We feel respected when we are given a range of things to choose from, ‘What would you like to do?’

Not- ‘Do you want to get admitted or will you take medicines!’

We feel dignified to have jobs/work that is meaningful to us, offering us sustainable means of living. Not being doped to the extent of not being able to get up and go about with my routine. Having prescriptions which look like grocery lists!

We are able to cross over crisis with enough supports around us.
Not when people are eyeing us suspiciously as ‘causing harm to self or causing harm to others!’ Not when there is a hurry to fix us, Not when there is a felt need to intervene!

People feel vibrant when they are eating right, people are able to connect to others in their social circles when they are not zombie-d.