The Bill attempts to reflect a change in the perception of institutionalised care but overlooks the wider socio-cultural and psycho-social determinants that impact mental health.
The Mental Healthcare Bill, 2013 has received a lot of attention since it was passed by the Rajya Sabha in August this year. In the Bill, provisions like decriminalisation of suicide, advance directives and nominated representatives introduce a rights-based approach for individuals. However, the Bill still operates on an individualised and medicalised paradigm of looking at mental health. This approach raises serious concerns as it overlooks the wider socio-cultural and psycho-social determinants that impact mental health.
The Bill has adopted a medicalised approach towards mental health by limiting itself to addressing healthcare services for ‘persons with mental illness’. It, therefore, precludes a whole section of the population who may not have developed ‘a substantial disorder of thinking, mood, perception, orientation or memory that grossly impairs judgment, behaviour, capacity to recognise reality or ability to meet the ordinary demands of life’ but are progressing towards such conditions. Studies have indicated that women constitute a large proportion of this population and are currently ignored due to the limited understanding of mental illness. The non-gendered understanding of mental health limits the current Bill’s provisions for women to sections like personal hygiene to be ensured in a mental health institution and the time period within which the medical officer in a mental health establishment has to report to the concerned board after the admission of an afflicted woman.
By saying that mental illness will not be determined on the basis of “non-conformity with moral, social, cultural, work or political values or religious beliefs prevailing in a person’s community” the Bill recognises the fact that often non-conformists are branded as suffering from a mental problem. This is true for a number of women. Women who deviate from the gender stereotype that portrays them as being subdued have been traditionally viewed as being ‘abnormal’ and often linked with conditions like ‘possession’ and ‘hysteria’. In her essay ‘Mental Health of Indian Women: A Field Experience’, Ajita Chakraborty argues that these instances could also be a mechanism by which women express their emotional difficulties which probably cannot be resolved through what might be called a standard way, but are viewed as cases of mental disturbance. Therefore, even though the Bill raises a pertinent issue of non-conformity, it does not dwell on it.
Clauses 29 and 30 of the Bill pay lip service to concepts of ‘promotion of mental health’, ‘prevention of mental illness’ and ‘sensitisation and awareness’ programmes to ‘reduce stigma associated with mental illness’, but do not elaborate on the processes for implementation of the same. The Bill has elaborated on the institutional mechanisms to be followed for treating persons with mental illness, the approach of health professionals but similar illustrations do not exist for implementing prevention activities, wherever it applies, or awareness around mental health.
Therefore, although the Bill aims to change the treatment approach towards persons with mental illness from providing institutional help and support to community-based treatments, it fails to elaborate how these community-based treatments would be implemented. The Bill discusses mental health establishments in great detail and deviates from its ‘aim’, restating and reinforcing the institutional approach to mental illness. Earlier programs on mental health, namely the District Mental Health Programme (operational since 1999), had similar objectives of prevention and awareness generation, and community-level treatment with mental health services being available at public health centres. However, 17 years later, the bill still states similar objectives which question the credibility of the bills commitment to creating awareness.
The rights of persons with mental illness have been incorporated in the Bill to ‘align and harmonise the existing laws’ with the Convention on Rights of Persons with Disabilities that India has ratified. Concepts like an advance directive, nominated representative and least restrictive environment have been detailed out in the Bill but the viability of these in the context of India remains a big question. The process required to communicate these entitlements and rights to persons with mental illness living in the communities has not been addressed, except in a cursory manner in clauses 29 and 30. Only when a person afflicted with mental illness visits an institution is there a chance that they might be informed about the rights that such a person has, when their rights may already have been violated.
The most discussed part of the Bill has been clause 124 which decriminalises suicide attempts, stating that “Notwithstanding anything contained in section 309 of the Indian Penal Code, any person who attempts to commit suicide shall be presumed, unless proved otherwise, to be suffering from mental illness at the time of attempting suicide and shall not be liable to punishment under the said section“. There is a need to see this clause in a different light. Yes, suicide attempt has been decriminalised but the person who attempts to commit suicide, as per this clause, would be given a separate ‘branding’ by being declared mentally ill unless proven otherwise. It is a well-known fact that there are several psycho-social factors which push a person to commit suicide and it may not necessarily be a mental disorder. The Bill however completely rejects this argument and fails to explore the underlying problems that lead to such suicides.
Thus, the Mental Healthcare Bill attempts to reflect a change in the perception of institutionalised care but is inadequate in addressing the component of community-based treatments. In a situation of a weakened public health system and lack of infrastructural support, it is difficult to envision a functional community-based care model. By espousing such a model in the absence of adequate public health infrastructure, it shifts the burden of providing care and treatment for mental health problems to the community.
To address the issues around the existing mindsets towards mental health and the stigma around it, there is a need to build supportive networks that create such awareness and not solely depend on the legal framework to bring about systemic changes.
Kalyani Badola, Amrita Gupta and Ruchi Bhargava work at Sama Resource Group for Women and Health, and are currently involved in an exploratory study on young women’s mental health