I would like to see more meaningful and relevant conversations between the medical community and society. My recent book, The Psychological Impact Of The Partition Of India (co-edited with Sanjeev Jain), looks at one example of this lacuna—Partition, its trauma and the psychological impact. We didn’t talk about the mental health part of such a big event, but this is not the only area where psychiatry and society did not speak to each other. Conversations between medicine and society are complicated, in and of themselves. The way people look at doctors is ambivalent: as those who have to heal, be altruistic, and are founts of knowledge. And the way medicine looks at society is just as complicated.
Psychiatry is strongly influenced by societal change. If you consider the recent hearings on Section 377 of the Indian Penal Code, the point becomes clearer. Till not so long ago, psychiatry looked at homosexuality as a problem. The Indian Psychiatric Association issued its position statement on it just last month, after all the years of activism around the issue. This is not, however, true for the individual. As you may be aware, a group of psychiatrists (of which I am one) is part of the initial group with the Naz Foundation, which filed a petition to remove Section 377. When society began to change its view of homosexuality, psychiatry did too. Knowledge grows incrementally. As we move from a position of what is good for society is good for the individual, to a position of what is good for the individual is good for society, changes take place in different spheres of living and thinking. It changes mental health laws, too, by deciding when involuntary treatment should be administered to a person, if at all. Legality involves deciding where one draws the line and who draws it. When we take a rights-based approach to it, are we talking of the family’s rights, society’s rights, individual’s rights—and is there also a right to treatment?
Society has certainly not been too respectful of the psychiatric gaze. There is a huge flux in the ways in which we look at whether mental hospitals are good or bad, who needs to get admitted, and the rights of the people who get admitted. The ways medicine and society understand illness are very different. The lack of conversation between, say, the right to treatment and the right to self-determination of a patient creates discord and dissonance. None of these rights, in reality, is inviolable; it has to be a discourse between the two, the humanitarian and professional approaches. We cannot be talking in silos instead of to each other.
Recently, in a ruling that made news, the Delhi high court ordered a person who had been admitted to a mental health hospital to be discharged. The question arises, who decides on the absence or presence of psychiatric illness? Is it the doctor, society, or court? And if a court decides a person isn’t unwell and discharges him, is the doctor then culpable? The clinical encounter is a tripartite phenomenon: between society, medicine and law, with an individual at its heart, and all of these need to be in communication with one another.
A couple of months ago, the Union health ministry came out with a poster which says that if you’re depressed, you should take long walks, eat multivitamins, travel, and so on. The problem is that it looks at mental illness from such a psychological point of view that it misses the biological or social aspects altogether. The fact is no problem is unitary in causation. Some people will need medication, some will benefit from therapy, everybody will benefit from long walks or travel.
The problem is partly due to medicine’s purely medical gaze being unable to incorporate any other gaze. Paradigm shifts should mean that we incorporate multiple paradigms in the way we look at the world, not discard them for only one. If we think of farmers’ suicides entirely in terms of anti-depressants, that would be absurd; if we look at them only in terms of long walks and multivitamins, that would be equally meaningless.
In the new Mental Healthcare Act, 2017 (which came into effect earlier this year), there is a provision called advance directives that fascinates me. It’s a societal communication tool, which gives agency to the individual to decide how they should be treated if they fall ill. In theory, this sounds perfectly fine. It was created as an olive branch to psychiatry, on the basis of what is known as the Ulysses contract. The problem becomes apparent depending on how we look at it: Are the wishes of this self that makes the decision valid or those of the other self that is ill? How can this self decide for that self? These layered and nuanced conversations have not yet begun among the various stakeholders—but they need to happen.
As told to Somak Ghoshal.
Alok Sarin, consultant psychiatrist at the Sitaram Bhartia Institute in New Delhi, is a leading physician and a pioneering mental health activist.