From amelioration to transformation: Hopes for mental health in human rights based systems – Sudarshan R Kottai

During my final year M. Phil Clinical Psychology course in 2013, a professor of Psychiatric Social Work who saw the title of my thesis with the phrase, ‘psychotic patients’ suggested changing it to ‘persons suffering from psychosis’ in line with UN Convention on Rights of Persons with Disabilities (UNCRPD). That was my first ever encounter with UNCRPD after being in the tertiary mental health care institution for two years.  None of the psychiatric social workers, clinical psychologists, psychiatrists or faculty members at the central government run institution did ever mention UNCRPD in the classes or the ward rounds. There were no seminars which raised critical consciousness about mental health from alternative perspectives at all. Neither were there training modules which enhanced the social justice orientation in thinking about mental health nor human rights based sensitization programs. In a nutshell, neglect towards human rights based language and action was rampant in   mental health education and training. The biomedical model often dictated by the psychiatrists was hegemonic, leaving no space for a justice-based model of mental health care. The focus was limited to diagnostic algorithms and established curative ‘protocols’. Conversations on what was going on outside the clinic to people and to society at large were unwelcome.  I was reprimanded for reading a newspaper in the ‘clinical’ space – Fish’s Psychopathology, DSM-4 and International Classification of Diseases-10 were only allowed -as it violated the norms of the institution.

Oppression and discrimination at mental health institutions

The huge boundary wall erected around the tertiary mental health institution during the colonial times was representative of the rigidity and insularity of the system. The colonial asylum, now transformed into a centre of excellence, was inherently violent in its attitude for it produced and reproduced knowledge for the sake of creating knowledge rather than producing knowledge with transformatory potential. There were rigid rules that lead many of us to the cusp of quitting such a horrible dehumanizing space. One of the students ran away from the institution unable to tolerate the torture inflicted by the faculty members. Another student who was poor in English was ridiculed and mocked during his very first seminar presentation. The clinical psychologist-faculty member pronounced the problem and its solution instantly- unfit for clinical psychology; better resign from the course. Such hurried, knee-jerk categorisations strived for uniformity and universality in behaviour, competencies and professionalism, giving no room for differences and deviances. I was constantly mocked at by teachers, co-students and seniors for wearing colourful dress, speaking in a low tone, for not being ‘masculine’ and hence not meeting their expected professionalism. One of the senior MD (psychiatry) students was especially interested to ‘diagnose’ my gender identity and sexual orientation that he used to regularly quiz me in public spaces of the institutions about my sexual preferences. I was given a number of diagnoses starting from \’adjustment disorder\’ to \’gender identity disorder\’ for questioning the discriminatory actions on the part of the institution (Kottai, 2014). While my own junior stayed in the hostel room after joining as a clinical psychologist, I was denied that facility stating that the hostel was meant only for students. The years that I spent for education and work at the mental health institution were the most tumultuous periods. posing some of the greatest challenges to my mental health, as the experiences I had navigating the space were often relational to who  I am, what body I had and whether I conformed to institution’s dominantly oppressive views and strictures.


Biopsychosocial model: A veil over the bio-bio-bio model


Though the rhetoric of   \’biopsychosocial model\’ being realized through the ‘mental health team’ consisting of the psychologist, psychiatrist, psychiatric nurse and the psychiatric social worker was preached at the centre of excellence, it never walked the talk. The synergy amongst them was almost always absent as the clinical psychologists struggled to huddle with the psychiatrists to be in ‘medical’ camp to feel high at the acme of ‘science’ against the   psychiatric social workers with their not so glamorous prefix- ‘social’ and the psychiatric nurses with subdued authority in comparison to doctors. Such hierarchical structures muted the voices for   participatory approach and multidisciplinary focus.  The uncritical acceptance of biomedical model percolated down to those in the lower rungs of the hierarchy, evaporated the biopsychosocial model, paving the way for a \’bio-bio-bio\’ model. Without a mind of their own, the psychiatric nurses, clinical psychologists and social workers reinforced the biomedical model professed by the psychiatrists. They never questioned the mainstream psychiatric knowledge production, research and practice which were too reductionist, medicalizing and dehumanizing and most importantly, always ameliorative in nature. These were instrumental in marginalizing thoughts for transformative change which included silencing of topics like UNCRPD and other rights based discourses. The mode of knowledge production, research and clinical practice at mental health systems are too ameliorative in nature without multiplicity of views and scope to think out of the box. The evidence-based medicine, evidence-based, algorithmic psychotherapies and polypharmacy are thrown indiscriminately at people who present with problems of living perpetuated by pathological systems and state architectures accentuated by insensitive, value-neutral technologists of the mind.


Ameliorative change to transformative change: From biopsychosocial model to inclusion

Ameliorative change involves perceiving, analyzing and responding to mental health problems from an individualistic perspective. Reducing ‘symptoms’ associated with distress remains the aim, e.g. a person who is shy is diagnosed with social phobia without delving into the toxic and chronic discrimination that he/she/they faces in his/her/their environment. CBT and anxiolytic medicines are prescribed to combat social phobia.  Here the clinician, in the name of treatment, commits double violence- misrecognizing the causes of suffering and individually ‘treating’ the child for a social problem that requires systemic change. Treating the child amounts to individualization, psychocentrism, biological reductionism and medicalization, whereby the responsibility of the problem and solution are abdicated from powerful oppressive structures responsible for causing distress are passed onto the individual. As a result, the brain and disordered ‘personality’ becomes the site for intervention and change at the expense of disordered structures and institutions. The child’s agency to act against oppression gets buried. Silence on the part of mental health professionals   feeds the oppressive structures to cast its shadow on mental health on a day-to-day basis. Individualized, ameliorative change is fraught with misrecognition and lack of critical consciousness leading to violence instead of safety in the name of mental health care. In addition to toxic stress that the child confronts on account of discrimination, there is   another label of social phobia that he/she/they needs to overcome by ‘adjusting’ to the oppressive societal structures. The individualized interventions like CBT act like a repair shop to repair the person’s thinking and behaviour regardless of the toxic ecological landscapes of suffering.

Transformative change calls for a perceptual shift in perceiving, analyzing and responding to problems of living through larger political, economic and socio-structural perspectives. Such change interventions will focus on the discriminatory structures that act as a constant barrier in realizing the need for positive social relations and community inclusion. The focus is on addressing the socio-structural determinants of mental health through policy changes, sensitization, legal interventions etc., other than altering child’s cognitions and neurochemicals without inviting the wrath of the powerful groups and without acknowledging the impact those systems have on mental health. Rather than fitting the child to the community, efforts in transformatory change looks at ways to fit community into people by being more accepting and inclusive of diversities. Transformative change is value-based, ecological in its outlook, oriented at human rights protection, strives for inclusion and works for a free and equal society.

The message in transformative change: Problem definition as an ethical issue

The metamorphosis from an individual perspective to a contextual, structural/ecological and macro system perspective changes problem definition and interventions applied to solve the problem. This requires looking at problem definition as an ethical issue. UNCRPD offers a value based, transformative human rights model of mental health care. E.g. LGBT people are ‘diagnosed’ with depression, medicated and subjected to conversion and aversion therapies. The UN Independent Expert on protection against violence and discrimination based on sexual orientation and gender identity in his report has time and again called for a ban on conversion therapies citing experiential accounts of torture in the hands of mental health professionals including from India. (UN, 2019). Unfortunately, there is no acknowledgement of suffering of LGBTQIA+ people as a consequence of a pathological system that fails to accept diversities and embrace differences. The Indian mental health community has been silent about the need to bring an anti LGBTQIA+ discrimination law and a ban on conversion therapy. Instead, amelioration becomes the sole focus of mental health professionals-  non-heteronormative people are labelled, responsibilised for their ‘depression’ and ‘anxiety’ exhorting them to change and adapt to the social norms and ideals depriving them of the moral support to be more assertive and agentic to claim identities and personhoods (Cris, 2020; Press Trust of India, 2018). Such ameliorative interventions are easy and profitable as it contributes to more ‘patients’, strengthens the authority to ‘treat’, accelerates prescriptions of medicines and individualized psychotherapies that heightens the influence, reach and visibility of mental health industry.

UNCRPD: No mental health without transformative change

Mainstream mental health professionals seldom speak for transformative change -equality, equity, autonomy, bodily integrity, justice and human rights for all – which has the potential to ‘cure’ their ‘patients’ forever. UNCRPD has given a whole new fillip to transformatory change in mental health care. Mental illness, framed as psychosocial disability, by the convention is a paradigm shift from biomedical model to the social model of mental health. It has moved the mental health discourses from the sole territory of the   psychiatric infrastructures to every other stakeholders including those who are suffering from psychosocial disability. Even though India is a signatory to UNCRPD the government and the mental health systems in India have not welcomed UNCRPD wholeheartedly. The state report on implementation of UNCRPD which is to be submitted every year was submitted by India after a long gap of 10 years in 2018.  On the top of that, there has been stiff resistance from the mainstream mental health professionals in devolving the power inherent in them since decades to ‘diagnose’ and ‘treat’ people with ‘mental illnesses’ to other non-psychiatric stakeholders for collective and multispectral action.  The loss of the medical in mental health and the rise of the social is ruffling feathers in the mainstream psy disciplines who promote scaling of up professional mental health services as the prime solution to psychosocial disability.  UNCRPD is cognizant of the human rights violations perpetuated by the mental health systems themselves. What we need is not such charitable gifting of ‘help’ from the professional ‘experts’ which creates a market for suffering. What we need is a human rights based approach to mental health where we are regarded as people with dignity and rights to be different and deviant from established societal norms that are exclusive and oppressive. Transformative change sits at an awkward tension with the increasingly industrializing mental health services that promises cures for all tensions through mushrooming counselling centres and psychiatric settings. In the name of development, mental health systems in India are increasingly medicalizing in its approach to mental health (Samudre et al., 2016). The focus on user-centric personal recovery is almost absent in the provider-centric mental health landscape with the latest mental health care Act 2017 speaking only about symptom recovery or clinical recovery. Alternative recovery models like peer support systems in India remain tokenistic, watered down versions heavily controlled by the powerful psychiatric establishments (Sharma, 2019a).  We need a UNCRPD compliant mental health system which doesn’t keep us chained in the mental health planet with only actors being mental health professionals, psychiatric establishments and colonial mental health laws controlling and deciding our fate.  It is high time mental health systems ventured out of their siloed clinics, singular narratives of mental health and profit motivated practice to lend voice to human rights without which mental health is never going to be within our reach. UNCRPD is completely absent in the popular mainstream mental health discourses as we don’t even see a copy of it on the websites of premier central government run mental health institutions like National Institute of Mental Health and Neurosciences (NIMHANS) for public dissemination and awareness.  There is a sheer negligence and motivational forgetting of UNCRPD inherent in such state-run power wielding institutions that hinders human rights reforms of mental health care. Unless people are aware of their rights, they cannot demand their fulfilment. Denying the information helps to maintain the skewness of power equation between mental health professionals and the people suffering from psychosocial disability.

The Bali Declaration 2018 by TCI Asia Pacific: Spotlight on transformatory change

Cognizant of all these facts, Transforming Communities for Inclusion (TCI) Asia-Pacific plenary meeting was held in 2018 in Bali, Indonesia. The outcome was the Bali Declaration  2018 which  cautions against increasing medicalisation of human distress by psychiatric systems in the Asia Pacific regions often legitimised by state sponsored mental health laws which are essentially colonial in nature. For e.g., we don’t see Nepal and Bhutan having a mental health law and it has also been found that mental health laws are not solutions for reforms in mental health system. In fact, high rates of institutionalisation and consequent terrors and traumas are seen in countries with a mental health law.

The Bali Declaration presses for a paradigm shift from the much-hyped biopsychosocial model to human rights based psychosocial approach where the two larger doorways of development and human rights need to be prioritised instead of narrow mental health doorway. The TCI insists for reframing the debate from mental health to inclusion.  It is a call for transformatory change in values that can impact mental health theory, praxis and research into one which is sensitive to social contexts, discriminatory state policies and closer to lived experiences of people with psychosocial disabilities.  Mainstream \’psy\’ disciplines have to move towards knowledge production that reduces context minimisation error, take the interest of the community and are courageous to disagree with profit motivated discourses of dominant professional groups that perpetually reduce choices through a single narrative of psychotherapy and medicine as solutions.  Just as society can impose great stress on individuals, an inclusive society can promote well-being.  Transformatory change that alters power relationships fuelling community action can only open the two larger doors of development and human rights.  Until and unless this is realised, people with psychosocial disabilities will remain engulfed in the vicious cycle of ameliorative change analogous to the musical chair which is structured for exclusion.  More choices and more voices can only provide multiple solutions to psychosocial disability which has multiple causes.

It is high time mainstream psychiatry reformed its apolitical, ahistorical, value-neutral and acontextual science to a discipline which recognizes the historical, political, value-based and contextual factors that have shaped what it means to be mental health. The ‘scientific’ hard language in mental health such as symptoms, diagnosis, disease and treatment are direct imports from medicine. In fact, there is nothing so ‘medical’ and ‘scientific’ in psychiatry, for its diagnoses and treatment modalities are fraught with criticisms and vehement opposition from within and outside the discipline. The quest to be ‘scientific’ in psychiatry is a reflection of medicine to be essentially value-neutral.  Psychiatry’s identity crisis and consequent struggles to be within the camp of medicine have been challenged by the presence of ‘many psychiatries’ (Rose, 2018) with varied ontological, epistemological and axiological differences. A value-based mental health system rooted in human rights and development for all is imperative to realise mental health for all.  Participatory decision-making, emphasis on social support and peer support collaborations need to be nurtured to resist the reductionist intrapsychic explanations of psychosocial disability by mainstream mental health systems that constantly perform context-stripping to engage in paternalistic ‘helping’ responses.  It is to be remembered that care has no limits unlike cure; Hippocrates said, “Cure sometimes, treat often, comfort always”; UNCRPD compliance is an essential step in resolving the “Mental health imbroglio: To treat or to heal?” (Sharma, 2019b).


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Acknowledgement: I am very grateful to Dr. Bhargavi Davar for sharing her experiences and thoughts on working for/with UNCRPD which have acted as fodders for me in penning this article.

Bio note: Sudarshan R Kottai is a RCI licensed clinical psychologist and has worked in the same capacity at Lokopriyo Gopinath Bordoloi Regional Institute of Mental Health, Tezpur, Assam, a tertiary mental health care institution. Currently, he is teaching at the department of psychology, Jain (deemed-to-be) University, Bangaluru, India.  Sudarshan’s doctoral work, carried out at the Department of Liberal Arts, Indian Institute of Technology Hyderabad revolves around everyday narratives and practices of mental health care and chronicity that are constructed by official discourses of state and bio-medicine. His research has been published in peer-reviewed journals such as Medical Anthropology: Cross-Cultural Studies on Health and Illness, Indian Journal of Medical Ethics and Economic and Political Weekly.  Sudarshan speaks to the following areas of scholarship: psy interventions with marginalised/minority population, mental health in the context of gender, disabilities and sexualities, and intersections in (public) mental health from multidisciplinary perspectives. He follows issues related to public administration that have direct consequences to life in general and human mentation in particular. Travelling, listening to music, reading literature and spending time with his pet dogs and other nonhumans on his farmland are sources of immense contemplations for him.