The World Health Organisation (WHO) reports that 450 million people worldwide are affected by mental, neurological or behavioural problems at any time. Furthermore, according to the WHO, most middle and low-income countries devote less than 1% of their health expenditure to mental health. Consequently, mental health policies, legislation, community care facilities, and treatments for people with mental illness are not given the priority they deserve. Barriers to effective treatment of mental illness include lack of recognition of the seriousness of mental illness and lack of understanding about the benefits of services. Policy makers, insurance companies, health and labour policies, and the public at large all discriminate between physical and mental problems.
Every woman, man, youth and child has the human right to the highest attainable standard of physical and mental health, without discrimination of any kind. This is enshrined in our Indian Constitution and the Universal Declaration on Human Rights. Enjoyment of the human right to health is vital to all aspects of a person's life and well-being, and is crucial to the realization of many other fundamental human rights and freedoms. Furthermore, the social right of victims of crime and their sensitive needs for mental health support is based on the Declaration of Basic Principles of Justice for Victims of Crime and Abuse of Power, 1985. (Resolution adopted by the UN General Assembly, non-binding principles upon member nations.)
Yet everyday, disparity in health care takes place in our country. People, needy, less fortunate or those born outside the system with mental health disorders are tied to their ward beds in the name of health care. Violation of their rights to dignity and respect are not uncommon.
The Indian institutional mental care experience
The Indian experience on institutionalised mental help as well institutionalisation of patients itself has not been civilising. A report prepared for the National Human Rights Commission (NHRC) in 1999 after an empirical study of mental hospitals in the country made a condemnation of the state of mental health institutions. "The findings reveal that there are predominantly two types of hospitals," the report said. "The first type do not deserve to be called 'hospitals' or mental health centres. They are 'dumping grounds' for families to abandon their mentally ill member, for either economic reasons or a lack of understanding and awareness of mental illness. The living conditions in many of these settings are deplorable and violate an individual's right to be treated humanely and live a life of dignity. Despite all advances in treatment, the mentally ill in these hospitals are forced to live a life of incarceration."
"The second type of 'hospitals',"the NHRC report continues, "are those that provide basic living amenities. Their role is predominantly custodial and they provide adequate food and shelter. Medical treatment is used to keep patients manageable and very little effort is made to preserve or enhance their daily living skills. These hospitals are violating the rights of the mentally ill persons to appropriate treatment and rehabilitation and a right to community and family life".
The NHRC released its report 6 years ago, but the conditions of persons with mental illness in institutions remain an urgent cause for human rights concern. In Gwalior Mental hospital, for instance, it was found that persons with mental illness were left in nakedness; the explanation was that they tore their clothes if they were given them.
Similarly, at Erwadi in Tamilnadu, patients who were chained to each other at a home for the mentally ill caught fire and killed 28 people in 2001. The press raised the issue. Chaining of mentally ill patients was also a practice, and has since then been outlawed by the reforms introduced by the Supreme Court of India that ensure that the fundamental rights of institutionalised patients are not violated. The ruling also set the climate for increased sensitivity on mental health support through actual mental health professionals.
Victims of crime and their mental care needs
Research and professional experience shows that secondary victimisation, generated either by institutions or individuals, is often experienced by victims in the aftermath of crime and leaves them in need of help. Secondary victimisation involves a lack of understanding of the suffering of victims which can leave them feeling both isolated and insecure, losing faith in the help available from their communities and the professional agencies. The experience of secondary victimisation intensifies the immediate consequences of crime by prolonging or aggravating the victim's trauma; attitudes, behaviour, acts or omissions can leave victims feeling alienated from society as a whole.
Secondary victimisation most recently appeared in an Indian courtroom on the 3 May 2005, when a convicted rapist proposed marriage to his victim. Secondary victimisation in itself is not an unusual phenomenon in our society. It most recently appeared in an Indian courtroom on the 3 May 2005, when a convicted rapist proposed marriage to his victim. The man was convicted of raping and seriously injuring the 22-year-old nurse in September 2003 at the hospital where they both worked. Minutes before sentencing was due on Tuesday 3 May, he issued his marriage proposal. Postponing the sentence until the next day, the Judge asked the victim whether she would accept the proposal from her attacker, who had hoped it might lower his sentence. The victim told the court she had rejected the offer.
Did the court as a dispenser of justice at all consider the dangers to women caused by such a precedent? If the convicted rapist said he was offering to marry the woman because the stigma of rape in India meant no one else would, do both judiciary and the law also have the same thinking pattern? What social responsibility was the court fulfilling?
Indian case law is missing mental health and rehabilitation aspects
Remarkable developments have taken place both internationally and nationally when it comes to prioritising child rights, but the links between child abuse, child labour and the care for a child's mental health are still absent. In India there is no separate law with regards to sexual assault of children. The general law on rape contained in the Indian Penal Code covers child sexual abuse and assault. Similarly, the Juvenile Justice Act 1986 has an impressive preamble, but despite this, the Act scarcely touches upon the subject of child sexual abuse, and completely leaves aside therapy and mental health considerations.
The role of mental health of rescued and victimised children is also absent in Indian case law. M C Mehta vs State of Tamil Nadu (AIR 1991 SC 417), is undoubtedly the most significant case on improving condition of children rescued from hazardous labour. Here it was argued that children below 14 years cannot be employed in any factory, mine or other hazardous work and they must be given education. The Supreme Court ruled that employers of children were made liable to pay Rs 20,000 in compensation for every child employed. The government was asked to provide job to an adult member of the family in lieu of the child or deposit Rs 5000 for each child. Thus there would be a corpus of Rs 25,000 for each child. The fund would be deposited in the "Child Labour Rehabilitation-cum-Welfare Fund". The payment made from the fund or the employment given would cease if the child is not sent to a school.
The M C Mehta case is most relevant for the understanding of a child's right to education after rescue from hazardous employment. There is however, one aspect missing in this case between the rescuing from child labour to the right to education. The long hours of work and monotony, the constant abuse and oppression for children in employment require the child's thorough mental health rehabilitation as a step prior to education. This was completely left out in the M C Mehta judgement.
Similarly, in Vishal Jeet vs Union of India (AIR 1990 SC 1412), the Supreme Court directed steps against child prostitution. One directive was on establishing advisory committees with experts from all fields to make suggestions regarding measures for a number of matters including eradicating child prostitution, care and rehabilitation of rescued girls and setting up of rehabilitation homes. The judgement did indicate a good understanding of the sensitive situation of children coming out of prostitution.
However again, the judiciary failed to understand the importance of defining 'rehabilitation' in its judgement. Experts may argue that defining such terminology is not within the mandate of the court. However, when directions concerning child rights are formulated it must be understood by law that either the inclusion of expert opinions is put in or that judges are sensitised towards issues such as child psychology. This should also be made applicable to the Juvenile Court, where a permanent position of a psychologist/mental health professional, is created alongside the judge to identify and precisely define directions on rehabilitation.
Civil Society responses alone won't do
Civil society groups and NGOs have recognized the lack of insight and priority amongst policy makers and legislators to mental health concerns. They have taken up the battle, generally though, in an unguided manner. Help-lines, friendly and non-professional counselling is given to patients in need of professional mental health support. This can amount to dreadful outcomes, when for instance a victim of domestic violence come to seek what in her view is guidance within the framework of counselling, but instead receives a cultural orientation on how the role of the Indian woman is to compromise and how with time the violence against the victim may reduce.
For example in Punjab, one slap a day for a woman is almost a matter of culture in some parts. So where and how do we start sensitising people of violence against women being a crime - in all forms, mental, physical and emotional? The International Centre for Research on Women (ICRW) suggests that 80 per cent men from Punjab think violence is justified if a wife is "disrespectful" and 60 per cent justify it if a wife "does not follow instructions". Such social customs and attitudes, which still consider women inferior, abet domestic violence. Scenarios where a woman comes to seek help in and receives counselling where she is brutally informed that "everything will be fine in due time" and that she must not leave her husband or abuser can result in very violent affairs.
The NHRC has emphasised the need of opening more than one women police thanas (stations) in a district of different states to deal with crime against women, but what is being done about the "cultural beliefs" in our legal system? In the meantime, every six hours, a young, married woman is burnt alive, beaten to death or forced to commit suicide, and one in five continues to face domestic violence from the age of 15. (NHRC 1999 annual report, national statistics.) This, when violence against women has been already been recognised as a human rights violation. Victims of violence, physical, sexual and even psychological, many women are today a statistic in the National Family Health Survey.
In several interactions I have had in Amritsar and Chandigarh with women's rights organisations and their helplines, I have learnt that individuals with no training in mental health counselling give advice in a majority of cases. There is currently no set protocol or system in place. This only makes it very difficult to assess whether the counselling offered meets victims' needs. Protocols and mandates have to be brought about on basis of which a counsellor can be judged. Failing the standards set should automatically lead to trial of the counsellor.
Similarly, many private initiatives where homeless victims and socially deprived are kept in homes and shelters, and are run based on the concept of 'humanity' and 'sewa'. Staff at these shelters may have no training whatsoever to attend to the special needs of victims or patients with psychological disorders. Still, it is difficult to criticise these groups which have stepped out to provide what our constitutional welfare state is overlooking. Not to forget the immense public awareness these groups are creating.
Civil society volunteerism can be an excuse for the state to withdraw from its role as a provider of health care. The state instead has to be made to fund group counsellors who help the women and children in their homes and shelters. The state cannot abdicate the entire responsibility to the non-governmental organisations; it has to play its role of welfare state. Also, the wrongful socio-cultural perception of the 'doctors of the mad', 'pagalo ke doctor', has to diminish, if our society is inclined to do justice to people in need of mental health care.
An expertise oriented approach needed
When society does not demonstrate responsibility to victims, pain and suffering is prolonged. In the longer term, the victimisation brings about adverse consequences on all aspects of the victim's life. Unsupported victims may, in the hope of protecting themselves, take refuge in self-defence or retaliation. Victims of crime, their families and those close to them ask, above all, for recognition of their suffering. This recognition should not be limited to intervention in the criminal justice process. Victims, as well as offenders, should be entitled to benefit from effective programmes of social reintegration.
Democratic societies have an obligation to alleviate the effects of crime, including the adverse consequences that victimisation has on all aspects of life. Victims must be supported in a way which shows an understanding of the whole range of their problems. All victims of crime have the right to ask for their privacy, their physical safety and their psychological well-being to be protected. Child victims in particular may experience difficulties obtaining support, either from their family or from professionals. Specialist services should be made directly accessible to them, and professionals made available to provide individual support for each child.
Ultimately, private initiatives as well governmental operations need inputs from professionals in the field of mental health, from psychologists and psychiatrists. Efforts to provide accurate support and right to mental health care cannot solely be left to any one group alone, whether civil society or governmental. A collaboration between the two, and a more expertise oriented approach towards mental health has to be realised. This becomes a must in a society such as ours where stigma and discrimination remain barriers mental health expertise reaching those suffering from mental disorders.