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The Mental Health Imbroglio

To Treat or to Heal?

Prateeksha Sharma (prateeksha.sharma@nalsar.ac.in) is with the Bright Side Family Counseling Center, Faridabad and does part-time doctoral research at the National Academy of Legal Studies and Research at Hyderabad.

The question that needs to be asked is, how many of those being treated for mental illness are recovering? Does the current treatment regimen help people with recovery, or is it only a “treatment” option with an entry and no exit point? Psychiatric professionals need to focus on recovery.

What could be a key question facing a society when it comes to mental health? Is it to identify people who are suffering for various reasons, medicate them and, keeping a medical view, invest in psychiatric infrastructure? Or is it to, like Mills (Rimke 2016: 4), take a social justice view, see the link between mental and emotional health/distress (private troubles) and social injustice (public issues)? The views taken in such policy decisions set priorities for further action.

Two Sides of Mental Health

From the point of view of someone who suffers, there are two sides to mental health: a point of entry into a psychiatric realm where their/their family’s distress is acknowledged, responded to, and then resolved. Do a majority of people who seek psychiatric intervention know they are entering into a lifelong dependence on medicines? Everyone believes they seek help to be relieved of their “symptoms.”

With the enactment of the Mental Healthcare Act in 2017, it is hoped that India would be able to align itself with the United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD) as well as bring the “values and principles of equity, justice, integrated and evidence-based care, quality, participatory and holistic approach to mental health” (Pathare et al 2018: 2). Does a legislation change anything for the average person who suffers due to a diagnosis of mental “illness,”1 unless the objective reality on the ground changes, or until professionals respond differently to mental distress rather than prescribing pharmaceutical options?

Existing Discourse

The psychiatric community in India bases its nosology (the branch of medical science dealing with the classification of diseases) from diagnostic categories created in the United States (US), which has a social reality vastly different from our own, via the Diagnostic and Statistical Manual of Mental Disorders (DSM), the American Psychiatric Association. All other psy-professionals also refer to the DSM as their bible. Of late, the Global Mental Health Movement is another step in consolidating the treatment orientation in mental “illness” and it is attempting to change government policy and expenditures towards further increasing psychiatric infrastructure.

This biomedical conception of people’s suffering is mediated through what Rimke (2016: 4) identifies as:

the “psy-complex” … a hegemonic formation … group of experts connected through their professional and social status, particularly psychiatrists, psychologists, psychiatric nurses, psychotherapists, psychoanalysts, and social workers.

Burstow (2013: 80) further argues that

psychiatry and its discourse are hegemonic because we believe in doctors, because “mental disorder” is embedded in law, because there are bureaucracies in every major city devoted to it, because the work of researchers throughout the globe is predicated on it, because a massive amount of public purse is spent on it, because a veritable army of state officials—“nurses,” “doctors,” “police,” “social workers,”—are paid to deal with it.

This is also the template adhered to in India. Davar (2012: 138) validates that “grassroots practice remains predominantly curative, biomedical and institution based.”

The problem with this discourse is that at present in countries of the global North many foundational principles of psychiatry are being questioned. Summerfield (2014: 406) notes that “at the heart of a crisis currently facing psychiatry is the failure of the dominant technical paradigm (which treated the mind as if it was an organ) to deliver what it has long claimed to deliver.” First, the idea that Western notions of illness could be the lens through which we could view our own people needs to be questioned, and then the imposition of knowledge from that context to India. In a bid to explain why the idea of transferring knowledge from the global North to the global South is untenable, Cox and Webb (2015: 684) note that in the South “notions of the individual, mental distress and expert authority are culturally distinct from Westernised societies.”

One is therefore tempted to ask why countries are adopting ideas which are not working in the very locations where they have developed. As it is, in poorer countries, healthcare is already beyond the reach of the average person. In what manner can psychiatric diagnoses take care of people’s mental distress, which oftentimes arises from problems of living and struggling with social inequities, whether it be poverty, hunger, unemployment, discrimination, war, genocide, or the numerous other socio-psychological determinants of health? The cumulative pain and suffering due to inequalities takes its toll on individual minds, hearts, bodies, communities—and far more on some social groups than others (Rimke 2016: 9).

When in the discourse itself, the focus lies on looking at suffering through a lens of pathology, and belief “that the right scientific tools can unlock such hidden secrets in the individual body or mind” (Rimke 2016: 8), the efforts to discover them continue ceaselessly, at the cost of human lives wasting into the ever lengthening dungeons of “illness” categories. People who are oppressed by their life struggles do not get an opportunity or option to recover, and whole families slip away into the abyss of poverty and infirmity.

Bioethicist Henk ten Have says,

Global differences in health are not just inequalities but inequities. If people are equal in a moral sense then justice should apply to all … The principle of equity expresses the idea that everyone should have a fair opportunity to attain health. (2016: 221)

Restoring Dignity

Possibly, the Mental Healthcare Act, 2017 is an attempt in the direction of creating that equity. Now mental health is implemented as a legal right which may be seen as a matter of justice that the act wants to restore to the suffering people, acknowledging that they have been denied their dues thus far. But can there be a legal provision and no pathways for its implementation, except by reinforcing the very system that is at times seen as part of the oppression associated with “treatment”? Kumar (2018: 101) notes, “[T]here are glaring gaps and omissions, and several compromises have been made in the name of adapting global principles to the Indian context.”

Before the act was promulgated, it was believed that

[P]ersons with mental illness should be treated like other persons with health problems and the environment around them should be made conducive to facilitate recovery, rehabilitation and full participation in society. (MOHFW 2013: 56)

However, by the time the act was implemented the idea of recovery was well-nigh done away with: not even once is the word recovery mentioned in the entire act. One would like to believe that the law is a matter of justice and “justice cannot be made a matter of charity” (Davidson 2010: 185). But, if people are not given freedom of choice and at least a few options to choose from, does freedom not become a farce?

Recovery as a Goal

Recovery2 in mental health is not beyond the reach of most. In fact, it may well be the other way round: a few may have major problems recovering. Does anyone ever talk of recovery? All one gets to hear is about the big or widening “treatment gap” indicating that while so many more people require psychiatric support, in fact a lot fewer are getting it. Therefore, there is a deficit of services, professionals and infrastructure that needs to be filled, which would ensure everyone is treated. The question that is not asked is: How many are recovering from the treatment they are getting? Does the current treatment regimen help people with recovery, or is it only a “treatment” option with an entry, and no exit points? What is the goal of such treatment? Is it to bring more people into psychiatric diagnostic categories, to sell more pharmaceutical products, or as Cohen (forthcoming 2021) questions, for “aiding the expansion of capitalism”?

Findings from Research

There is nothing implicit in the manner in which depression or schizophrenia are defined. Yet, this would have been the lesser of the problems had treatments brought empowering outcomes to those diagnosed so, instead of disabling twists in their stories, with progressively worsening prognosis. What could have been passing phases of “abnormal” (assuming there is a universally acceptable “normal”) behaviours due to environmental stressors become reified as mental illness, once diagnosed. Researchers routinely draw attention towards the socially constructed nature of the human mind, the manner in which we perceive and represent what we take to be “reality” and as an extension the manner in which mental illness categories are defined.

My own research in understanding recovery in serious mental illness indicates that recovery is possible, achievable and sustainable, equally in resource-scarce countries like India, as much as in the global North. By recovery I do not refer to mere remission, but drug-free, personal recovery, as opposed to a mere clinical recovery. However, even though I am one such person today, in nearly two decades of treatment I have never heard the word “recovery” from any psychiatric professional, and neither has anyone who is part of my research now. Commenting on this, Davidson et al (2010: 185–87) note that

well-meaning practitioners often agree in principle with this goal, but suggest that it is not yet the right time, or that we do not yet have the requisite means, to achieve it. Their patients are too sick or disabled to recover; there is not yet an adequate evidence base to support … [they] are at times ‘more devoted’ to symptom reduction and skill acquisition than to the person’s day-to-day life, and that they at times “paternalistically believe” that they can set the conditions for their patients’ self-determination or participation in the life of their communities.

If one were to leave recovery to professionals alone, there may be no incidence of recovery anywhere. One cannot but agree with Martin Luther King, Jr (qtd in Davidson et al 2010: 184) that “Justice for one party cannot be made contingent on or left up to the whims of another party, as in that case it will inevitably be delayed indefinitely and, as a result, denied.” Recovery from mental health issues is a matter of justice for millions after all.

Notes

1 I refer to mental “illness” within parenthesis because I do not believe in the reductionistic category of mental “illness” as a definitive truth or reality about anyone, which can be factually proven via any medical or measurable means.

2 The theme of recovery is also the area of my forthcoming doctoral research and the scope of this article permits me only to refer to it in a lay perspective, rather than delve into the contrary manner in which it is conceptualised theoretically by different groups of people.

References

Burstow, Bonnie (2013): “A Rose by Any Other Name: Naming and the Battle against Psychiatry,” Mad Matters: A Critical Reader in Canadian Mad Studies, B A LeFrancois, R Menzies, G Reaume (eds), Toronto: Canadian Scholars’ Press Inc, pp 79–90.

Cohen, Bruce M Z (forthcoming 2021): “A Postcolonial Critique of Mental Health,” Routledge International Handbook of Race, Ethnicity, and Culture in Mental Health, R Moodley and E Lee (eds), Abingdon: Routledge.

Cox, Nigel and Lucy Webb (2015): “Poles Apart: Does the Export of Mental Health Expertise from the Global North to the Global South Represent A Neutral Relocation of Knowledge and Practice? Sociology of Health & Illness, Vol 37, No 5, pp 683–97.

Davar, B V (2012): “Gender and Community Mental Health: Sharing Experiences from Our Service Program,” Community Mental Health in India, B S Chavan, N Gupta, P Arun et al (eds), New Delhi: Jaypee.

Davidson, Larry, Jaak Rakfeldt, John Strauss (2010): The Roots of the Recovery Movement in Psychiatry—Lessons Learned: Wiley-Blackwell.

Kumar, M T (2018): “Mental Healthcare Act 2017: Liberal in Principles, Let Down in Provisions,” Indian J Psychol Med, 40: pp 101–07.

MoHFW (2013): “The Mental Health Care Bill 2013,” Ministry of Health and Family Welfare, http://mohfw.nic.in/WriteReadData/l892s/mental%20health%20care%20bill%20....

Pathare, S, J Kalha and S Krishnamoorthy (2018): “Peer Support for Mental Illness in India: An Underutilised Resource,” Epidemiology and Psychiatric Sciences, Cambridge University Press, Vol 27, No 5, pp 415–19.

Rimke, Heidi (2016): “Introduction—Mental and Emotional Distress as a Social Justice Issue: Beyond Psychocentrism,” Studies in Social Justice, Vol 10, Issue 1, pp 4–17.

Summerfield, Derek (2014): “A Short Conversation with Arthur Kleinman about His Support for the Global Mental Health Movement,”Disability and the Global South, Vol 1, No 2, pp 406–11.

ten Have, Henk (2016): Global Bioethics—An Introduction, London and New York: Routledge.

Updated On : 30th Apr, 2019

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