Mental health care in India

Every day, thousands of health seekers of different faiths, the mentally ill and the spirit-possessed, travel from villages and cities to faith healing shrines dotted throughout Tamil Nadu that are reputed for their curative powers.

Some seekers are guided by the common belief that their mental illness is caused by possession of evil spirits or a curse placed upon them by a jealous neighbour or relative. Others visit shrines as a last resort after taking ineffective biomedical treatment.

The belief that one’s mental illness is caused by possession of an evil spirit incurs little stigmatisation, and this culturally-accepted explanation does not portray the ill person as a victim. On the other hand, there is a social stigma associated with mental disorder and psychiatric treatment. For example, if it is common knowledge within a community that an unmarried girl has received psychiatric treatment, her marriage prospects are severely hindered. Therefore, seeking religious help for spirit-possession at shrines (which may be Hindu, Muslim or Catholic) is socially sanctioned. Some devotees stay at shrines for weeks in hopes of a permanent cure, and will use services offered by priests, local healers, astrologers and exorcists, as the sacred is often perceived as playing a crucial role in the healing process.

The fire at Erwadi

In 2001, a fire occurred at the Erwadi dargah, a Sufi Muslim shrine in Tamil Nadu that is highly popular for its reputed miraculous powers to heal the mentally ill. The fire killed 28 people with mental illness who had been chained up in the surrounding boarding houses used to confine residents. Sensational media reports portrayed the Erwadi tragedy as a result of ‘backward’ traditions that needed to be overcome by enlightened modernity. The media also revealed that psychiatric services were in a poor state across most of the country, and psychiatrists generally conceded the shortcomings, citing poor government commitment. There were widespread calls for the modernisation of the mental health sector. At the time, Tamil Nadu’s formal mental health care system was in a better condition than most other Indian states.

Since the Erwadi fire, governmental attempts to reform the formal mental health sector have gained force. A 2016 report of the National Human Rights Commission (NHRC) identifies the progress made, as well as the “glaring gaps” that still exist in mental health care in the country – where mental illness is estimated to affect seven per cent of the current population. The report found that there are only 47 public psychiatric institutions throughout the country, and the number of inpatient beds in India is well below the global average. An estimated 6,000 psychiatrists are active (one per 2,000,000 per head of population of 1.2 billion), which is below the global average, and many of them are in private practice or emigrate overseas. The numbers of trained clinical psychologists, psychiatric social workers and psychiatric nurses are far lower. Overall, the NHRC deems there are significant human resource shortages, inadequate rehabilitation and recreation facilities, “closed ward” structures still in existence in some hospitals, and variability in monitoring and a lack of systematic planning.

On the positive side, today there is a reduction in involuntary admissions and better living conditions for patients. There have been significant transformations in psychiatric hospitals, with improved facilities, infrastructure, food and drugs. Outpatient services have improved, and institutions are making efforts to engage more with the community. There are more than 325 NGOs working in the mental health field, which is an improvement over the last decade, but still deemed grossly insufficient for a country of 1.2 billion people.

The situation in Tamil Nadu and Pondicherry

The report places Tamil Nadu and Pondicherry near the top across most measurements, including the number of institutions: Tamil Nadu has one dedicated government psychiatric institution (the norm per state), provides psychiatric care in a high number (27) of district hospitals, has 80 private institutions, and has the highest number of NGOs working in mental healthcare (121). While Pondicherry does not have a government psychiatric hospital, it delivers substantial psychiatric care through its general hospitals, and the number of private centres is on the rise. This prevalence of services somewhat reflects the high rates of mental illness in Tamil Nadu and Pondicherry. Pondicherry reports the second highest annual suicide rate, after Delhi, and is closely followed by Tamil Nadu. In particular, Tamil Nadu has experienced a spate of farmer suicides in the last months, which has been linked to the recent failed monsoon.

Effect on healing shrines

The Erwadi fire and subsequent mental health reforms have not had much influence on the functioning of healing shrines. The vast majority simply ignored government attempts to make them interface with psychiatric services. Some shrines vehemently resisted state attempts at intervention – possibly due to the fundamental mismatch between the world-views of psychiatry and religion. Erwadi itself reportedly resisted all attempts at intervention for many years, but eventually agreed to implement some psychiatric services, and this is underway now.

A few shrines cooperated with attempted intervention programmes (which largely failed). One temple, the Gunaseelam temple near Trichy in Tamil Nadu, which has an enduring reputation for curing mental illness, established an attached rehabilition centre in cooperation with a psychiatric hospital in Trichy. The centre’s programme aims to treat patients affordably within a community setting in a way that synchronises with their religious beliefs. The healing regimen includes religious healing from the priests five times per day in the temple, and biomedical treatment from a psychiatrist who visits a few times a week. Patients express positive experiences, saying they believe more in the power of the god than biomedicine.

New Mental Health Care Bill

One of the most significant reforms post-Erwadi is the introduction of a new Mental Health Care Bill 2013 which seeks to replace the outdated Mental Health Act of 1987. The new bill was approved in the Rajya Sabha in 2016, and is now awaiting ratification by the Lok Sabha.

The bill has certain progressive features and lays down clear responsibilities for states, and aims to fulfill India’s stated mandate to the United Nations Convention on the Rights of Persons with Disabilities (CPRD), which India signed in 2007. The bill aims to protect the rights of people with mental illness and ensure they are not discriminated against. It makes mental health treatment a right, focuses on making positive changes to the mental health care infrastructure, and aims to provide expanded access to treatment. It reduces doctors’ power to commit patients to psychiatric treatment centers without their consent, and forbids electroshock therapy without anaesthesia and muscle relaxants. It also decriminalizes suicide, stressing the need to rehabilitate such individuals. It aims to uphold patient confidentiality and obligates the government to create shelters and halfway houses for the mentally ill. State governments will be compelled to establish their own mental health authority, and integrate mental health services into primary, secondary and tertiary health care.

A notable feature of the bill is the introduction of advance directives: this gives people suffering from a mental illness the right to choose their mode of treatment, and to nominate representatives who will ensure that their choices are carried out. This ensures that mental illness does not rob an individual of decision-making capacities, and instills the idea that they are entitled to a life of dignity.

The new bill has also drawn a fair share of criticism. It largely adopts a biomedical model to treat mental illness, and does not acknowledge other healing modalities. It only recognises the role of psychiatrists in the treatment of a mental illness, and it focuses on the requirements of people in mental healthcare facilities, which is only a small proportion of the mentally-ill.

While the new legislation is directed at the formal mental health sector, thousands of people continue each day to visit faith healing shrines. These liminal spaces between the everyday and sacred spheres of life are often the first and last port of call for mental health seekers. A stay in a shrine is not merely the last hope for recovery or a cheap refuge. It allows the mentally ill person to act upon their faith, because the first and last hope of recovery is often based on faith.