Behind the asylum walls
CHENNAI: Dr Poorna Chandrika, a professor in the Department of Psychiatry of The Institute of Mental Health remembers seeing a decaying postcard that had enquired about a brother residing in the asylum. There were other postcards sent by the institute to their loved ones asking them to visit the patients, but visits were rare. There was a time when mental illness was a byword for madness and treatments translated to isolation and fetters around arms and ankles. However, the scenario is perceptibly changing with advancements in the field and revisions in the nature of care and cure.
It was during the British administration in India in the 18th century that the management board decided to have health care in the then Madras. In 1793, the current Institute of Mental Health (IMH), which is one of the largest and oldest institutes in South Asia, was incepted. For decades, since the genesis of this institute, custodial care was practiced rigorously, wherein the patients were locked up. Dr Sanjiv Jain, Emeritus professor at NIMHANS says, “During those times when medications were not introduced to the world of psychiatry, the use of native therapy like blister treatment, hot and cold showers, and so on were performed on patients.”
A turning point
It was only in the 1930s that anti-psychotic medicines and electroconvulsive therapy were introduced, and in the 1950s, modern drugs, tranquilisers, anti-depressants were prescribed. This groundbreaking step into the field of psychiatry immensely helped in mitigating many painful treatments. The number of solitary confinement cases also came down significantly after the advent of medicines. Dr R Thara, co-founder and vice chairman of SCARF, says, “The NHRC study on mental hospitals brought the issues about solitary confinement to the fore.”
Today, solitary confinement is considered an act of human rights violation. Allegations of inhumane dealings in asylums were heard over and over, and these harsh conducts were an offshoot of shortcomings in infrastructure, which led to overcrowding. Dr Sanjiv Jain says, “Constant allegations and media coverages have also driven reforms in the domain. For centuries, there was no escape route for people who were admitted to institutes, which was the overriding cause of overpopulation.”
Dr Kishore Kumar, the director of The Banyan, an NGO working to help people with mental illnesses, echoes this concern and says, “This issue led to a movement of deinstitutionalisation in the state, and as the concept of long-term stay in asylums started to die away, there was less dependence on the institution, giving them the agency they deserve and ensuring a good quality life.” Many people who recuperated from their illnesses were accepted in the community, but the downside was that for many, going back to their family was a dreadful thought, and for the other section, they had no place to go back to.
Beyond medications
It was gradually discerned that the connotation of care transcended medical interventions. Mental health care started sprawling, giving rise to many NGOs. Dr Kishore says that the birth of The Banyan was a social response to the looming miseries of the underprivileged with mental illnesses. He says, “Home is the best place for recovery.” With this notion, the organisation started providing outpatient clinics and community-based care; and for people who need long-term care, an inclusive living space with pyscho-social support.
Their initiative Home Again was recognised by the World Health Organization as one of the long-term care and was added in the 21 interventions across the globe.
While there have been advancements like an increase in the number of mental health practitioners, private players, NGOs, and attention given to long-term care in recent years, when we leaf over the pages of history, some horrendous incidents were blotching the mental health care sector.
A tussle of faith and science
Dr R Mangala, a consultant psychiatrist of SCARF says that following the 2001 Erwadi tragedy, where 26 people with mental illness tied to trees were burnt alive in a fire outbreak, there was a shift in the delivery of services. “It was only after this incident that district mental health care services started functioning efficaciously, despite these services being on the paper for many years.”
Being a state entrenched in faiths and superstitions, it was hard to disrupt people’s belief systems, and faith healing could not be uprooted fully. Gunaseelam Vishnu Temple near Tiruchy, known as a healing place for people with mental illnesses, has an age-old tradition of keeping people with mental illnesses in the temple premises for a certain period.
Today, there is a government-licensed rehabilitation centre, where the patients are administered medicines. Along with this, the temple rituals are also followed. This exemplifies the adoption of a middle ground and see how temples and clinics work in tandem. Dr Mangala also recalls the conceptualisation of dava-dua (where people are convinced that medications can subdue symptoms and treat them, without questioning their belief system) she had seen in many dargahs of Puducherry, while she was working there.
Dr Sanjiv acknowledges the mental health practitioners — Dr Dhairyam, Dr D Sharada Menon, Dr O Somasundaram, and Dr Venkoba Rao who made IMH an active teaching place, and improved the situation substantially. Dr Poorna, also expresses her admiration towards their commendable contribution by introducing occupational therapy in 1949. She says, “The patients were encouraged to engage themselves in baking, gardening, weaving, tailoring, carpentry, etc.”
Expectations
On government intervention, Dr Sanjiv says, “The government is investing in mental health care programme, and each district has a psychiatry section. However, there should be a long-term plan for 20-30 years, because there is a large section of people who may remain ill for a large part of their life, and may not recover. Therefore, attention has to be given to this group of people and their care too.”
Dr Kishore who believes that the notion of controlling people with mental illnesses has gradually changed into providing a patient-centric service says that one of the challenges we face in the country is acceptance of the under-privileged mentally ill by society and the system.”