Mental healthcare speaks an idiom unfamiliar to patients. A major conference calls for a radical rethink, reports DR RAKHAL GAITONDE. 

THERE ARE three types of visitors to Kovalam, a bustling village about 12 kilometres from Mahabalipuram on the East Coast Road towards Chennai. Schoolchildren from the surrounding villages are the noisiest lot, followed by the tourists and the scores of people coming to visit the local dargah that is famous for its faith healers. The setting couldn’t have been more appropriate for the recently held conference ‘Mental Health at the Margins’, organised by The Banyan, a local NGO that works with the homeless mentally ill, in collaboration with the University College of London. The conference had the overall objective of evolving “a broad definition and understanding of theory and practice related to mental health and marginality from both Western and South Asian perspective.”

Going beyond an exchange of ideas, the conference raised a challenge to the existing “bio-medical” model of psychiatry with its narrow and reductionist view of what constitutes mental illness. One of the key points of view that emerged from the discussions was the need to broaden the definition of mental illness by using inputs from social scientists as well as those whom the mental health system is designed to serve. Also articulated was the need to examine the ways in which traditional societies deal with mental illness — research indicates these are often more successful than conventional psychiatry — rather than dismissing them off-hand as “primitive”.

The timing for the conference couldn’t have been better. The World Health Organisation’s Global Burden of Disease study has projected mental health problems to be the most important cause of ill health and disability in the near future. Overall, participants felt that it was time to take a serious look at the existing mental health infrastructure and its ability to conceptualise, diagnose, treat and prevent mental illness, and the government’s commitment and capacity to deal with mental health needs.

The village of Kovalam is a case in point. In the past few years, locals here have helplessly watched their familiar landscape change beyond recognition. It started with a crop of chemical industries that brought in their wake considerable environmental and health hazards. Then the construction of the East Coast Road through the area brought its own set of problems, particularly an increase in the number of road accident deaths, most of them of local bystanders. These were just some of the factors that destroyed the livelihoods of Kovalam’s residents, and led to an alarming rise in mental health problems. The conference also noted that, thanks to the inadequate mental healthcare system, faith healers were the only recourse available to the populace to cope with the new pressures.

The example of Kovalam serves as a context to understand the larger reasons that lie at the root of most mental illnesses. Summing up mental healthcare in general, and particularly in the Indian setting, the conference raised three major points. First was the need for the existing infrastructure to be upgraded, both in terms of qualified personnel as well as equipment and facilities. Second came the need to strengthen the general healthcare system, given the extent to which it is linked to that of mental healthcare — not just because mental and physical health cannot be viewed in isolation from each other, but also because at a functional level both systems are inextricably linked, both in terms of infrastructure and delivery.

The third and the most crucial point raised by the conference was the urgent need to re-think the current approach to mental illness as an exclusively bio-medical phenomenon, and recognise the complex interplay between social, economic, political, cultural and environmental factors behind it. Such an approach would mean that the way forward in tackling the growing mental health crisis is not to just “fill the gap” through techno-managerial “more of the same” solutions, but to effect a structural overhaul of mental healthcare and a radical rethink of the concept of mental illness itself.

For instance, in the case of a woman who is suffering from domestic violence, it is not enough to say that she’s depressed and give her anti-depressants. Sure enough, medication helps in overcoming the immediate crisis, but unless the underlying causes are addressed, medication and treatment will be of little help to the patient.

It is important to recall here that the very structure of contemporary Indian society, the very model of “development” that is being madly and blindly followed, is in itself creating a huge impact on health, and especially on mental health. Those most affected, typically, are those who subsidise the obscene lifestyles of the upper strata of society by living on less than a dollar a day, by skipping meals, by living on the streets, by going hungry to bed, by selling off their children, by becoming commercial sex workers and by building the houses and factories that populate the nation’s collective dreams.

The conference noted how even today, the major part of the burden of mental healthcare in India is still borne by traditional healers, mostly faith healers based around popular places of worship. Rather than dismiss their contribution, it is important for mental health professionals and policy makers to note the fact that such traditional methods — rejected outright by the Western model of psychiatry — have often proven to be effective in providing cure for certain illnesses, notably in cases of acute psychosis.

There has been considerable research done to support this, particularly the studies undertaken in 1980 by a team of psychiatrists based at the National Institute of Mental Health and Neuro-Sciences, Bangalore. One of the key reasons for their success, the study concluded, was that traditional healers used a socio-cultural idiom that was familiar to the patients, especially those in rural communities — such as concepts of possession or ancestor worship — unlike modern psychiatry, whose idiom was alien to them.

Participants at the conference made several incisive presentations on the cultural and social basis of mental health which attempted to bring new perspectives on mental health and raise challenges to the bio-medical paradigm. Other discussions centred around issues such as rituals and their place in healing, and performance of local-level mental health programmes. The interactions with Banyan inmates provided a glimpse of the ground reality of mental health problems on the margins of society.

There was an appreciation of the various dimensions of mental health, especially its complex nature and its organic intersection with issues like caste, gender and poverty. Also looked at was the influence these “social determinants” had on the way mental stress is expressed in different cultures. Such close examination inevitably led to the conclusion that a purely technical approach to mental health was inadequate, and even inappropriate in understanding the ways in which traditional communities cope with mental illness and related pressures, since they are virtually inseparable from local socio-cultural realties.

THE NEED really is to hear the voice of the people, taking into account the immense contributions of the social sciences. In the words of the late anthropologist George Foster, “The striking thing about these questions is that almost all assume that effective healthcare can be achieved only when members of traditional communities change their health behaviour. Rarely, if ever, is the question asked: “How can anthropologists help to change bureaucratic behaviour that inhibits the design and operation of the best healthcare system?”

The conference concluded with a call to mental health professionals to better understand how the current mental healthcare system inherently marginalises the very people it is meant to serve through its myopic methods. In the final analysis, it is the margins that define the centre, and this conference by focusing on margins and on marginality afforded those at the centre to introspect and to look critically at the “lenses” they use and the “spaces” they occupy. The task ahead is no doubt a difficult one, but to the participants it was clear that what was called for was nothing less than a radical shake-up.

The author is a community health researcher-activist working in Tamil Nadu

From Tehelka Magazine, Vol 5, Issue 10, Dated Mar 15, 2008

Source: http://www.tehelka.com/story_main38.asp?filename=cr150308shrinking_from.asp#