Mental health in India

There is a sharp contrast between Western invented indicators to describe mental health services and the prognosis of 'severe mental illness' (schizophrenia).

WHO World Mental Health Atlas gives the following facts:

Psychiatric Beds and Professionals
Total psychiatric beds per 10 000 population 0.25
Psychiatric beds in mental hospitals per 10 000 population 0.2
Psychiatric beds in general hospitals per 10 000 population 0.05
Psychiatric beds in other settings per 10 000 population 0.01
Number of psychiatrists per 100 000 population 0.2
Number of neurosurgeons per 100 000 population 0.06
Number of psychiatric nurses per 100 000 population 0.05
Number of neurologists per 100 000 population 0.05
Number of psychologists per 100 000 population 0.03
Number of social workers per 100 000 population 0.03
There are 200 mental health workers of other types. One third of mental health beds are in one state (Maharashtra) and several states have no mental hospitals. Some mental hospitals have more than 1000 beds and several still have a large proportion of longstay patients. During the past two decades, many mental hospitals have been reformed through the intervention of the voluntary organizations (e.g. Action Aid India), media, National Human Rights Commission and judiciary (courts), and yet a survey in 2002 showed that about a quarter had shortages in terms of drugs/treatment modalities and three quarters in terms of staff. The current emphasis is on general health psychiatry units that support voluntary admissions and encourage family members to stay with the patient. Some beds are allocated to treatment of drug abuse and for child psychiatry. Very few mental health professionals are based in rural areas. Most states allow public sector psychiatrists to have private clinics. Many mental health professionals have emigrated. (World Mental Health Atlas 2005 http://www.who.int/mental_health/evidence/atlas/profiles_countries_e_i.pdf)

In contrast to the above poor image is the prognosis of schizophrenia.
"...the prognosis of certain mental disorders, e.g. schizophrenia, is better in developing countries. It is vital to identify factors that make it so, and the changing role of family, urbanisation and rapid Westernisation, especially with economic liberalisation and the influence of satellite television, cannot be underestimated. As the editor of the Journal under review asks in his editorial, "Are some of our problems like increased social unrest, waves of agitations and protests, the menace of drug abuse and the arrival of the dreaded evil of AIDS due to rapid social change? Could it be that technological growth has not only provided prosperity to a few but the parallel boom in telecommunications and information technology has brought into sharper focus
the economic disparity and the gulf between the rich and the poor?". These are relevant questions from the perspectives of the psychiatrist, not only in India but also in developed and other developing countries." (DINESH BHUGRA, Indian Journal of Social Psychiatry Vol. 8 3/4)

Then comes my question: is it acceptable to promote Western mental health and psychiatry without criticism while ignoring the fact on better prognosis in the name of right to health? What human rights are at stake? Who listens to users of services and their movements?


Ahová érkezem: Hyderabad

Június 1-én késő éjjel Hyderabadba érkezem, ahol 11 napot töltök. Hyderabad lesz indiai tartózkodásom alatt az egyik főhadiszállásom. Itt a helyi jogi egyetemmel fogok együttműködni, főként az ENSZ fogyatékosjogi egyezményének megvalósításával kapcsolatban, de előadok egy gyermekjogi konferencián is és a központi egyetemen is.

My destination and one of my headquarters in India

Late at night on 1st June I shall arrive at Hyderabad. Here follows a brief introduction to this wonderful city. (From http://www.hyderabad.co.uk/introduction.htm)

Introduction to Hyderabad

The capital of the state of Andhra Pradesh, Hyderabad is the fifth largest city in India with an ancient civilisation and culture. Attached to the city is its twin , Secunderbad, which is part of Hyderabad. The twin cities of Hyderabad and Secunderbad are separated by the Husain Sagar, an artificial lake constructed during the time of Ibrahim Quli Qutb Shah Wali in 1562 A.D.
The city is nearly 400 years old and is noted for its natural beauty, mosques and minarets, bazaars and bridges, hills and lakes. It is perched on the top of the Deccan Plateau, 1776ft., above sea level, and sprawls over an area of 100 Sq. miles.
A multitude of influences have shaped the character of the city. Its palaces and buildings, houses and tenements, gardens and streets have a history and an architectural individuality of their own, which makes Hyderabad a city of enchantment.

Hyderabad was founded on the River Musi five miles east of Golconda, in 1591-92 by Muhammad Quli Qutb Shah. In the 16th century the city grew spontaneously to accommodate the surplus population of Golconda, which was the capital of the Qutb Shahi rulers. Many buildings sprang up along the River Musi. Gradually the city grew.

The Qutb Shahi dynasty founded the Kingdom of Golconda, one of the five kingdoms that emerged after the break up of the Bahamani Kingdom. The Qutb Shahis ruled the Deccan for almost 171 years. All the seven rulers were patrons of learning and were great builders. They contributed to the growth and development of Indo-Persian and Indo-Islamic literature and culture in Hyderabad. During the Qutb Shahi reign Golconda became one of the leading markets in the world of diamonds, pearls, steel for arms, and also printed fabric.

The glory of the Golconda kingdom ended in 1687, after a valiant struggle. Aurangzeb, the last great Mughal ruler, captured Golconda after a siege that lasted eight months. Abul Hasan Tana Shah, the last king of Golconda, was imprisoned at Daulatabad, where he died after twelve years in captivity.

With the conquest of the Deccan and the South, Aurangzeb succeeded in expanding the Mughal Empire to cover the entire sub-continent. However, after his death in 1707, the Empire rapidly declined.

At that time , the Deccan was administered by a Subedar or viceroy of the Mughal Emperor. Mir Quamaruddin, the Governor of the Deccan, who bore the title of Nizam-ul-Mulk Feroze Jung Asif Jah, declared his independence from Mughal rule in 1724. He thus became the first Nizam and the founder of the Asif Jahi dynasty.

Asif Jah I continued to maintain Aruangabad, which had been founded by the Mughal rulers as the capital of his new state. In 1769, Nizam Ali Khan Asif Jah II, shifted the capital to Hyderabad. The seven Nizam's of the Asif Jahi dynasty ruled the Deccan for nearly 224 years, right up to 1948.

During the Asif Jahi period, Persian, Urdu, Telgu and Marathi developed simultaneously. The highest official positions were given to deserving persons irrespective of their religion. Persian was the official language up to 1893 and then Urdu up to 1948.

When the British and the French spread their hold over the country, the Nizam soon won their friendship without bequeathing his power. The title "Faithful. Ally of the British Government" was bestowed on Nizam VII. The British stationed a Resident at Hyderabad, but the state continued to be ruled by the Nizam.

The rule of the seven Nizam's saw the growth of Hyderabad both culturally and economically. Huge reservoirs, like the Nizam Sagar, Tungabadra, Osman Sagar, Himayath Sagar, and others were built. Survey work on Nagarjuna Sagar had also begun during this time.

Hyderabad, under the Nizam's, was the largest princely state in India. Area wise it was as big as England and Scotland put together. The State had its own currency, mint, railways, and postal system. There was no income tax.

Soon after India gained independence, Hyderabad State merged with the Union of India. On November 1, 1956 the map of India was redrawn into linguistic states, and Hyderabad became the capital of Andhra Pradesh.

Extracted from "Hyderabad, A City in History" by Raza Alikhan


My host in India: the Bapu Trust

Bapu Trust for Research on Mind and Discourse was established as a formal institution in the year 1999. Our project office (Centre for Advocacy in Mental Health www.camhindia.org) was started in August, 2000.

"Bapu" is the personal name of a Tamil woman, who was born of a culturally and materially elite family in Chennai, Tamil Nadu. She heard voices, saw visions, wrote religious verses in Tamil and Sanskrit, and believed herself to be in deep connection with god. She was labeled with "schizophrenia" and ended up wandering on the streets. She was deserted by her family, and struggled for daily survival, even though she came from a very wealthy background and had a huge property and a large family in Chennai. She lived many years of her adult life, wandering and alone, in some healing temples of Kerala. She wrote poetry, sang bhajans, wore the dress of a monk and shaved her head. She drew and painted her visions, sometimes with great flourish and bursts of colour. She was "caught" by the police many times and forcibly brought back to a hostile family environment. She was subjected to many invasive treatments and psychiatric abuse, including lock up, solitary confinement, insulin coma, several dozens of shock treatment, repeated and forced institutionalizations, and many disabling anti-psychotic medications, on a trial and error basis. She suffered severe and debilitating side effects of the treatments, including severe tardive dyskinesia, Parkinson's disease and muscular dysfunction. Various traditional methods were also tried out on her, such as dhara, exorcism, etc. She passed on in the autumn of the year 1996, struck by stroke and coma. One of "Bapu's" two children, Bhargavi Davar, founded the trust in her memory and with her legacy.

Some saw "Bapu" as "mad" and "bad", others saw her as spiritual, creative, intuitive and gifted. Bapu Trust for Research on Mind & Discourse, like "Bapu", journeys the grey areas between madness and creativity, insanity and spirituality.

Bapu Trust does not have any affiliations or connections to political parties of any sort.

Vision [New vision being developed]
In Bapu, we want to see a world, where emotional well-being is experienced in a holistic manner, as an experience of "total wellness". Wellness is not just being symptom free, but being deeply connected with one's inner source of creativity, joy and freedom. Bapu dreams of therapeutic environments in the world, where every person can reach into and use their own capacity to make choices, heal themselves, recover and move on. Such environments will also be rich in love, warmth and nurturance, and will enable people's higher aspirations for growth, pleasure, joy and creativity, using compassionate, non-violent, non-hazardous and playful means. Bapu sees and partakes of a world of healing environments, based on a philosophy of care, freedom and fairness.

Mission [Being developed]
We will create, pilot and monitor programs and interventions that enable self-reliance and a life of dignity, among persons with psycho-social and psychiatric disabilities. Such programs will connect with people's aspirations and potential, and promote their positive mental health. We will work towards enhancing and promoting the emotional well being of persons in vulnerable positions (women, poor, children) and other communities in need. We will create innovative preventive programs in the community, so that the burden of psychological ill health in the community is reduced. We will strive to change the structural, social, legal and policy environment, so that they remain just and fair to people with a psycho-social disability. We will work with people with psycho-social and psychiatric disabilities, so that they can get good quality mental health care and can live in an unbiased society, with knowledge, understanding, dignity, self-determination and self-respect. We will fight unfair, forced or abusive mental health interventions. We will strive to keep our own work environments, program areas and working team spaces caring and mental health enhancing.

Scope of our work
Bapu Trust is a group of academics, researchers, advocates and healers, working towards creating alternative visions and streams of practice, in mental health care in India, which is presently dominated by biomedicine.
The Trust is the only national level organization totally devoted, in its programs and activities, to critically questioning the bio-medical model widely practiced in India. We are committed to an empirical approach to consumer empowerment and we conduct mental health advocacy research. We research on service development, gender studies, policy studies, legal research and human rights based action research in mental health. Bapu brings a humanistic, developmental and rights based approach to mental health work. Bapu is an innovative program developer in community mental health. At present, we have developed Seher, a psychotherapy program and are in the process of developing Setu, a program for the homeless mentally ill based on therapeutic community model. Bapu is a capacity building resource organization, working closely and co-operatively with grass roots organizations and NGOs on the one hand, and with civil society institutions, mental health professionals, and the government on the other, in implementing its vision.

Bapu was founded by Dr. Bhargavi V Davar. It was co-founded by Dr. Amita Dhanda, a professor of law at NALSAR, a Central University of Law, sited in Hyderabad. Dr. Dhanda has been a teacher - researcher - activist, with various publications to her credit on the interphase between poverty, law, mental health and disability. She has been on various consultations and progressive forums, aiming to make structural changes in the mental health and the disability sector. Other co-founders were Mr. Pramod Kumar Davar, Ms. Sujata Venkatraman and Mr S D Verma, who have since left the Trust, due to other commitments. At present, other trustees of Bapu are:
Dr. Raghu Rama Raju, Reader (Philosophy), Central University, Hyderabad;
Ms Lakshmi Rao Buchamma, educationist and teacher, Hyderabad;
Dr. Sadhana Natu, activist and teacher, Dept. of Psychology, Modern College, Pune.
All the trustees have a background of several years of sound research, high intellectual outputs as well as a history of participation in diverse and progressive forums for social change.
Bapu staff, working at CAMH, are social science researchers (background in sociology, archaeology, political science, psychology, women's studies), social workers, psychotherapists and counselors.
Bapu Trust has a representation of persons with users and ex-users of mental health services among its Board members as well as staff, though not equal representation at this moment.

National Mental Health Care Givers’ Training Workshop

Organised by the Center for Advocacy in Mental Health, 27th and 28th June, 2008, BAIF Campus, Pune.

Facilitators: Mr Gábor Gombos and Bhargavi Davar

Care providers, whether they are family members, or the cadres of community care providers, are important constituencies influencing the Indian mental health and disability sector. Being well organized, care providers’ organizations and networks have brought about significant changes in the mental health sector, showing that they are a formidable advocacy force to reckon with.
In the last decade, several individual family care givers, the care givers’ organizations as well as service providers at the community level, have faced acute dilemmas about the protection of persons living with a mental illness and intellectual disability, versus their freedoms. These dilemmas have been particularly intense, against the backdrop of the UN Convention on the Rights of Persons with Disabilities [CRPD].

Individual users, the few users’ collectives in the country, disability activism and the increasing stories of violations of users’ rights have strengthened the need for a rapid rethinking of values in the mental health sector. Family members and primary care providers in health programs have to humanely deal with users who are open about their dissent to the treatment being given or to their family environment, in a highly resource poor sector.

While the CRPD centers the person with psychosocial and intellectual disabilities, applying the CRPD in the immediate context of family and community requires much reflection, process and skill. This is a long term activity, involving the creation of a new set of assumptions and premises, hitherto absent in the mental health sector. It also involves new practices and programs. Family members have agonized over the lack of alternatives and very poor availability of wholesome resources in mental health. There is the realization that it is time to invent new strategies and programs of our own, and not wait for largesse from various agencies.

Objectives of the National caregivers’ training workshop:

- To explore the personal worlds of care givers and their own distress / well being experiences
- To help participants acknowledge their own interests and needs in the process of care giving
- To help care givers identify areas where they can do something in order to make their own lives and their cared ones' more humane and livable
- To invite participants to explore together what the CRPD principles mean for them and for their cared ones

Participants (Max. 30)

Who will find the training program useful:
- Individual family members who are caring for someone with a psychosocial or intellectual disability
- Sponsored participants from family care givers’ organizations dealing with intellectual or psychosocial disabilities
- Service providers in primary health care from various treatment, counselling or psychotherapeutic backgrounds working with psychosocial and intellectual disabilities
- Any one else who sees themselves as having a humane role to play in the care of a person living with a psychosocial or intellectual disability
[For users of mental health services, look for news or write to us about our forthcoming National User Workshop]

In a safe emotional environment, conducive to promote communication and open dialogue, the sessions will use multiple methodologies, including the lecture method, building upon self experience.

Dates: 27th and 28th June, 2009, BAIF Campus, Pune
Registration and fees: A nominal fee of Rs. 250/= is being charged to each participant. DDs may be sent in the name of “Bapu Trust for Research on Mind & Discourse, Pune”. Modest accommodation at the venue is available at Rs. 435/= per day per person. You may want to share your room with another participant to save on cost. Subsidizing accommodation can be considered for people who are unable to support themselves. We will provide reading materials, food and snacks during the workshop days.

Contact for more details about the program: Bhargavi and Maitreyee, CAMH
Logistics: Elizabeth, Yogita, CAMH
Contact details:Center for Advocacy in Mental HealthKapil Villa, Ground Floor, Survey No. 50/4, Plot No. 9,Satyanand Hospital Lane, Kondhwa Khurd, Pune 411 048Ph: 020-26837644, 26837647Emails: info@camhindia.org ; wamhc@dataone.in

Six months exchange programme in India

Visit by Mr Gabor Gombos, Mental health & Human Rights scholar and activist from Hungary, June 2008 - November 2008

The Bapu Trust for Research on Mind & Disourse is facilitating a 6 month visit by Mr Gábor Gombos, from Hungary. Gábor Gombos, a former theoretical physicist and survivor of psychiatry, has become a world-renowned advocate for the rights of persons with psycho-social disabilities. For over a decade, and until 2006, he chaired Hungary’s only network of user organisations (Hungarian Mental Health Interest Forum). During this time he liased with self-advocacy groups and local user NGOs with the relevant authorities, including local municipalities, members of the Parliament and the national govenment. The Forum had gained official recognition by the legislature and local and central policy makers while maintaining its grassroots character. Gábor focussed his efforts to train self-advocates and local advocacy groups. He and the Forum has extensively contributed to recent legislative reforms in Hungary, including the legal ban on the cage beds that had been widely used in psychiatric facilities to restrain people. He also contributed to relevant amendments to the social care act and to the development of standards for alternative, non-coercive, community-based services for persons with psychosocial disabilities.

The Mental Disability Advocacy Center in Hungary advances the human rights of children and adults with actual or perceived intellectual or psycho-social (mental health) disabilities. Focusing on Europe and central Asia, they use a combination of law and advocacy to promote equality and social integration. Gábor is Senior Advocacy Officer at MDAC, leading their intergovernmental and national level advocacy. In this role he has extensively advised intergovernmental bodies, such as the Council of Europe, the European Commission and the United Nations on disability rights issues and has participated as a delegate of the civil society in the work of the UN Ad Hoc Committee which drafted the new Convention on the Rights of Persons with Disabilities. Gábor was profiled in the project, Speak Truth to Power as one of the 51 select leading human rights defenders around the globe. He is a Fellow of Ashoka: the Global Association of Leading Social Entrepreneurs. Internationally, Gábor acted as chair of the European Network of (ex-)Users and Survivors of Psychiatry, a European umbrella of national NGOs of persons with psychosocial disabilities until 2004. Currently he serves as deputy chair and regional board member for Central Europe. Between 2001 and 2003 he extensively worked as a consultant in Kosovo to help self-advocacy initiatives.

Need for this exchange:

Persons living with a mental illness can be the best advocates for themselves as well as for their peers. This potential is hindered by many obstacles, each of them rooted in the stigma associated with disabilites in general and with psychosocial disabilities in particular. Discrimination against persons living with a mental illness affect every aspect of private and public life. Having a psychosocial disability or even a family member with such a disability is a taboo in many societies including India. In most societies persons with psychosocial disabilites belong to the most marginalised, disenfrenchised, disempowered groups of people, who are kept invisible, whose voice is not heard and not listened to.
While in India important steps have been made by a number of disability rights activists, human rights defenders and academics working in the field, the movement of self-advocates, advocates who are persons living with mental illness themselves, has not yet started. India has much potential to approach psychosocial disability in an innovative way, partly based on its traditional healing, spiritual sensitivity, and the like.

The objectives of the international exchange:

Gábor Gombos’ work in India has the following objectives:

- To create a non-combative, safe environment where public discourse on the need for and viability of self-advocacy of persons living with a mental illness is encouraged.
- To facilitate such a discourse in different settings and with different stakeholders.
- To engage as much as possible in this short period of time, with the in-country processes of CRPD implementation with respect to various Acts and laws.
- To develop and test training and audio visual materials that can be used by Bapu Trust to train supporters and future self-advocates.
- To inform stakeholders on the issues by doing the activities, including speaking arrangements, lectures, media appearances and the like. All these objectives are planned to be realised through a collaborative and participatory process.

Plans for Gábor’s visit

Gábor aims to work with a wide diversity of constituencies in the mental health sector while he is here. We are looking for collaborations where Gabor can actively interact with groups of users and survivors of psychiatry, and other mental health sector leaders. He will develop and conduct workshops on Self advocacy for persons with psychosocial disabilities, for various mental health constituencies. Training programs for care givers using the Self Advocacy model is also being considered. The Bapu Trust is also happy to receive collaborative proposals for public lectures and seminars from research and training institutions, particularly relating to the CRPD, on which he has expertise. Strategic or policy level meetings, consultations in different parts of the country with legal, research and human rights institutions would also benefit from his contributions.

Write to us:

During his visit, Gábor Gombos is working in close collaboration with Bhargavi V Davar and Amita Dhanda. Bhargavi Davar [Ashoka Fellow] has extensively used the medium of writing to bring visibility to the situation of people with psychosocial disabilities and to advocate for structural reform. She has a self identity as user / survivor and has used multiple methods (research, trainings and campaigns) to fight coercive practices within the Indian mental health system. She is an active member of the World Network of Users and Survivors of Psychiatry, a global coalition for user rights. She is editor of a newsletter called Aaina (meaning ‘Reflections’), which facilitates user empowerment in India, and human rights issues in the field of mental health. Along with Dr Amita Dhanda, she started the Bapu Trust, a national organisation which is using a multi pronged approach to influence change within the mental health system in India. Bhargavi Davar is director of various research projects and campaigns at the Pune office, both regional as well as national / international. The organisation also runs a non-medical recovery program for psychosocial disabilities, using psychotherapeutic and art based mediums. Amita Dhanda finished her Ph.D. from the University of Delhi, critically examining the laws relating to mental illness. She served 15 years at the Indian Law Institute, New Delhi. She is a Professor of Law at the National Academy for Legal Studies and Research [NALSAR] in Hyderabad, India. She is an internationally known legal expert, researcher and advocate, focussing her work on Disability laws, particularly in the context of psychosocial disabilities. She has published several books and edited volumes, including Legal Order / Mental disorder [Sage Publications, 2000]. She has served on and led important judicial and policy commissions, such as the Commission for Inquiry into the condition of custodial institutions in West Bengal. She was Chairperson of the National Amendment Committee of the Persons with Disabilities Act, 1995. She has fully participated as a civil society representative in the Ad Hoc Committee Meetings of the India ratified, United Nations’ Convention on the Rights of Persons with Disabilities. She is founder trustee of the Bapu Trust for Research on Mind & Discourse, India.

Contact address of all collaborating partners:
Gábor Gombos, gombosg@yahoo.com, ggombos@mdac.info
Bhargavi Davar, bvdavar@gmail.com, info@camhindia.org
Amita Dhanda, amitadhanda@gmail.com
Organisational support for the Exchange: Bapu Trust for Research on Mind & Discourse, India. HQ: Survey No. 50/4, Plot No. 9, Kapil Villa, Ground Floor, Kondhwa Khurd, Pune 411 028 (T): 0091-20-26837644, 26837647
Administrative contact at Bapu: Ms Yogita Kulkarni, Senior Team Service staff.
Email id: info@camhindia.org, wamhc@dataone.in
URL: www.camhindia.org