Billing it right on mental health

It’s been over 20 years since Vandana Gopikumar helped rescue a mentally ill homeless woman in Chennai. Along with friend Vaishnavi Jayakumar, they managed to take the woman off the street to get her some treatment and care.

But the experience and others that followed revealed the absence of a “systemic response” to handle such situations, recounts Vandana, reflecting on the incident that triggered the birth of The Banyan, a centre for mentally ill people.

In fact, the Mental Healthcare Bill (2016) passed recently by the Rajya Sabha (RS) aims to improve the environment for mentally ill by protecting their right to better healthcare and services. [This was one of two Bills passed by the RS, the other being The Maternity Benefit (Amendment) Bill, 2016 – see Anchor below).

Though the Mental Healthcare Bill has taken close to 30 years in coming (it replaces the Mental Health Act, 1987), some are calling it a “watershed” Bill.

The focus earlier was on institutional care with little attention on life beyond the hospital. There was no infrastructure to support recovery and rehabilitation, says Vandana. The approach now is more integrated and the expectation is to eventually move towards community based care, she explains.

The Bill mandates access to healthcare and that is a huge positive, she says, as anyone concerned about the wellbeing of a mentally ill person can engage with the healthcare system to get better support. But it should not get interpreted as merely stocking psychiatric drugs at Primary Healthcare Centres. The effort should include therapeutic interventions and social care facilities, she adds.

Paras Sharma, programme coordinator of iCall (a free psychosocial helpline at the Tata Institute of Social Sciences), says the Bill has been “massively overdue” and fits in with the legacy of laws that are great on paper.

The earlier approach was to “protect” people from the mentally ill. So while the latest Bill mandates access to healthcare as a right, it will be a while before mindsets change on the ground, he observes.

The Bill decriminalises suicide and talks about counselling and support. But it is ambiguous on the corresponding repeal of Section 309 of the Indian Penal Code (under which a person attempting suicide faces arrest), he says.

Outlining areas that need more attention, Sharma says, the Bill allows for “advance directives” by a person on how to be treated if mentally ill. How would this be implemented and what if it is violated, he asks.

Clarity is also needed on the prohibition of electro convulsive therapy; the option of voluntary admission and discharge and insurance coverage, who provides it and what gets covered.

Presently, meagre funds despatched to health centres are often sent back to the Government, because the thrust is not on mental health, observes Sharma. And though better infrastructure and more professionals are required in the area of mental health, the Bill takes a “myopic view” on professionals by not recognising consulting psychologists, for instance, he says.

Where the Government goes from here, in terms of a plan on mental health programmes, is critical. They need adequate funds, doctors and support staff, for example, for the policy to come alive, says Vandana.

As reports emerge with disturbing regularity on mentally ill residents being chained or treated badly, to put it mildly, it is clear that institutions are over-whelmed by the numbers. There are people who live and die there, says Vandana.

Caring for the mentally ill needs to shift to smaller and more humane centres, she says, even if it means taking bold steps like shutting down large institutions or overhauling them to approach mental health differently.

The effort should be to treat someone who is mentally ill and rehabilitate them back into their families, with support structures like group living or community care. This will mean a crucial shift, so people don’t live out their entire life in an institution.

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