|Year : 2019 | Volume
| Issue : 1 | Page : 4-9
Social psychiatry in India: Current changes and challenges
Institute of Mental Health, Pt. Bhagwat Dayal Sharma University of Health Sciences, Rohtak, Haryana, India
|Date of Submission||01-Mar-2019|
|Date of Decision||08-Mar-2019|
|Date of Acceptance||08-Mar-2019|
|Date of Web Publication||27-Mar-2019|
Prof. Rajiv Gupta
Institute of Mental Health, Pt. Bhagwat Dayal Sharma University of Health Sciences, Rohtak - 124 001, Haryana
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gupta R. Social psychiatry in India: Current changes and challenges. Indian J Soc Psychiatry 2019;35:4-9
Dear Colleagues and Friends,
I am sure you had a very fruitful, exciting, and enjoyable conference benefitting from the well-crafted scientific and educational program in this educational city of Rohtak, Haryana. I hope you also had a good time meeting your old friends and colleagues from all over India and exploring the culture of North India and Haryana, in particular. I had the privilege to be the President of this great association for the past 2 years, and it has been an exciting time to work with the wonderful executive team. It was a great honor to end my term by hosting this landmark Silver Jubilee Conference. I would like to focus on the contemporary changes and challenges in the field of social psychiatry in India.
Psychiatry in the mid-19th century adopted the biomedical model, reducing mental health problems to brain diseases that needed treatment by pharmacological interventions targeting biological disturbances. This neglect of the psychosocial dimensions of the disease and reducing mental illness to purely physical factors not only ignored important determinants of health and disease but also failed to integrate the issues that were important for comprehensive care. The biopsychosocial (BPS) approach proposed by Engel four decades ago culminated and integrated biological, psychological, and social factors to play a significant role in disease causation and treatment. This changed the way of conceptualizing illness leading to a holistic, integrated as well as a humanistic approach in the delivery of health care. Hence, while the biological basis of the illness is now being pursued by many disciplines, the task of making the broken ends of psychological and social issues to join up was left entirely to psychiatry.
There is a large body of evidence suggesting the importance of social determinants for mental disorders. Several forms of social issues and problems find their origin in the religious and cultural practices that vary from region to region. Factors such as substantial urbanization, different levels of economic stability, civil unrest, gender discrimination, sexual harassment, and widening social gap are invariably related to increased rates of mental disorders. Indian society is a complex mix of diverse cultures, people, beliefs, and languages, and the very same complexity imbibes in itself a plethora of social problems and issues.
In the current era, which has turned out to be an era of reforms in almost all the spheres, the medical profession is also seeing lot of changes. Be it the Mental Health Care Act (MHCA), 2017, dissolution of Medical Council of India (MCI), or attempts to increase the postgraduate medical seats, all these reforms will have a tremendous impact on the health-care delivery system in one way or the other. We have to wait to see how these changes effectively handle the ever-increasing demands of the health system. In wake of the recent judgments where many important and traditional concepts of society were washed away, including decriminalization of homosexuality and adultery, it will be apt to add that law will have a strong control over the management of health-care delivery. Time has come to add a legal dimension to the BPS model of Engel, making it a bio-psycho-social-legal model.
We as psychiatrists are aware of the complex interface these determinants and social changes have with the mental disorders. The challenge is how to address these determinants, majority of which are not modifiable or need intense inputs for successful management. For the purpose of discussion, I have organized these changes and challenges into four overlapping perspectives – social system, health-care system, legal system, and issues specific to mental health [Table 1].
| Social System|| |
The social system is undergoing drastic changes at the moment, and issues of violence, loneliness, and sexual harassment along with conflict with social organizations such as Khaps are important issues and need focus by social psychiatrists.
First, it would not be inappropriate to say that aggression and its outward expression has become a new norm in the current scenario. Women, children, the weak, and the helpless remain the subject to such violence due to one or the other reasons, and in one form or the other, be it violence against females, mob lynching, or violence against doctors. Rampant domestic violence against women in India is a matter of concern. Apart from criminal laws such as Section 498 and Section 304-B, the Protection of Women from Domestic Violence Act emerged as a civil law, which tends to restrain the abuser from committing violence and provides support to the women faced with violence. However, Acts have their own lacunae as they include no provisions regarding marital rape, which is a form of domestic violence and often remains unreported. Another issue is that of the allegations of misuse of the Act by women wherein no provision has been made for the women to be held liable in case of misuse of the Act by them. Although improvement can be seen over the period of time with new case laws, a lot still needs to be done. On a similar note, an equally embarrassing fact is that India has one of the highest incidences of female feticide in the world. Despite various laws in this regard, the problem is still increasing. Moreover, sex selection through in vitro fertilization and other technologies such as preimplantation genetic diagnosis, preimplantation genetic screening, and sperm sorting have emerged as the next challenge toward curbing female infanticide. Education and empowerment of women is a powerful tool, and raising the age of marriage, acceptance of family planning, and improvement in self-image would definitely help in fighting the menace of female feticide. Another aspect of violence, that is, mob lynching related to rumors about suspected child lifters and kidnappers, cow trafficking and killing, and beef consumption, has resulted in the murder of numerous people in the recent past. Fake social media messages whip up a frenzy in minutes, and before any sanity can prevail, innocents have been literally clobbered to death. People are mobilized in seconds with the help of social media, giving real-time details of the event leading to violence. The State and Central Governments must take preventive, punitive, and remedial measures to stop such episodes of lynching. Violence has also engulfed the medical profession, and the doctors have become quite vulnerable. We are living in an era where doctor bashing, vandalizing of clinics, and politicizing of issues have become a trend. As such, daily incidents of violence are being reported from all over the country. Moreover, casual comments about the medical services on the part of public representatives to gain public sympathy have become a habit, thus tarnishing the medical profession.
The second major concern is the growing lack of social connectedness. Life in the current era is a life in a virtual world, where loneliness has been emerging as a great issue. Eric Klinenberg in his book, “Going Solo: The Extraordinary Rise and Surprising Appeal of Living Alone,” has described this soloness and the “increasing me time” as the world's biggest change in the past few decades. The extent of this problem has not been realized in spite of changes in this regard in every dimension of the everyday life – the family structures are changing, the way apartments are designed is changing, companies are restrategizing, and even food outlets are now changing themselves to accommodate singles. Recently, the day 11/11 (four solitary sticks) was celebrated as single's day in China. A similar trend is being seen in South Korea as “Honjok” lifestyle, a neologism meaning the alone life, where singles are picking passion over partners. The self-absorbed individual with a selfie stick in hand would be a great challenge to the social psychiatrists in the coming year.
Third, the rapid spread of the #MeToo movement millions of women around the world shared their traumatic stories through social media. Almost, every country in the world has had its own #MeToo moment since then, and so has India. Globalization, connectivity, and this movement have been on spot in creating an environment where women are able to share their worst experiences. They have felt that they are not alone and their experiences are being believed as well as understood. Women can now speak on what may constitute harassment. However, like many other social campaigns in the past, there is a lack of a clear action point and it only serves as a token act. Furthermore, it has a potential to be exploited to harness one's own agenda by fake victims and thus may make the movement to be discredited, when the truth gets exposed.
Fourth important move pertaining to the social system is related to social organizations, which act as quasi-judicial bodies having great impact on the specific groups. In this context, “Khap panchayats” have long claimed to perform their duties as conscience keepers of the society. Although they form useful instruments of the society having a strength of its own and which can potentially carry out social reforms, their inflexible and rigid approach bring them to disrepute. The Supreme Court in its recent verdict on March 27, 2018 ruled that the interference by illegal assemblies, such as “Khap” panchayats, in marriages of two consenting adults is “absolutely illegal” and laid down guidelines to prevent such intrusions. “Khaps,” which have been devoid of representation of women as well as youths and lack the rush of novel ideas and changes in societal norms, have thus been at loggerheads with all those who try to follow new trends in the society and appear to challenge their authority. This has led them to be visualized as an imposing institution meant to ensure continuation of systems of patriarchy without any setbacks. Hence, education of the masses, so that they can come out of the corridors of caste and have compassion for the marginalized sections such as women and youths, is the need of the hour.
| Health-Care System|| |
Our health-care delivery system has been undergoing rapid and major reforms. Changes in the medical education, dissolutions of the medical council, two-way attrition in the relationship between the doctors and the patients, specific implication of sexual harassment, and the associated “#MeToo Movement” in the medical field are major concerns.
First concern is the rapid expansion in medical seats in the past few years with a trend favoring privatization, which has led to the increased proposition of UG and PG seats in India to the tune of 60,000 and 35,000, respectively. As a result, the past two decades have witnessed improved doctor-to-patient population ratio namely, 1:3800 in 2001 to 1:921 in 2018 (WHO), although the number includes Ayurveda, Homeopathy, and Unani (AYUSH) practitioners also. However, it is evident that the accelerated growth of medical seats at both the UG as well as PG level to overcome deficits in the health sector in an overpopulated country such as India has failed to achieve its desired impact; this approach has instead led to another series of formidable challenges concerning quality. A huge gap has been created between dynamic quantitative growth and static quality of education and now needs urgent attention. Multiple factors seem responsible for the creation of this lacuna, ranging from maldistribution of resources, static traditional curricula, and a poor assessment system, coupled with neglected research and untrained faculty. Furthermore, with the medical curriculum undergoing a change by the end of the year 2018, it remains to be seen how much impact it would have on the quality of medical education.
Second, in a major move, the Central Government dissolved the MCI, in accordance with the NMC Bill (2017) and replaced it with a seven-member board led by NITI Aayog Member (Health), which is aimed at reforming the medical education sector. However, the Bill has been opposed by the medical professionals equivocally throughout the country, who fear that such a move will cripple the functioning of the medical profession by making it completely answerable to the bureaucracy and nonmedical administrators. Achieving high growth in healthcare to meet the growing needs is an area of high priority and may necessitate a reform, but replacing MCI with another regulatory body does not guarantee that the current issues in medical education will be resolved, and the basic reason for dissolving the MCI, that is, corruption, would necessarily be addressed effectively by this move. Only time will tell whether this replacement would evolve into a better model than the previous one.
Third issue which demands great focus on our part is the failing doctor–patient relationship, which has seen rapid deterioration in the past few years. The skewed doctor–patient ratio, lack of infrastructure, inadequate supporting staff, and long-working hours for doctors result in increased stress and work pressure, thereby impairing the doctor–patient relationship. The situation where law and society has started viewing patient as customer with all consumer rights and medical profession as a business with all taxes applicable as like other businesses yet expecting doctors to remain noble healers and not just as service providers further worsens the situation. Unrealistic expectations of the people at large that a doctor must revive every patient they bring in for medical care and in whatsoever condition, and if the revival cannot be done, it is the doctor who is to be blamed, makes doctors more vulnerable to dissatisfaction and violence. At the same time, corporatization of health-care sector has reduced the relationship between both parties into just a commercial exchange. These days, doctors only “see” their patients but do not spend time with them and counsel them properly. With escalating mistrust on both sides, the task to restore the glorious doctor–patient relationship remains a big challenge.
Finally, with the #MeToo movement going viral to fight sexual violence and harassment in the workplace, the field of medicine is also not spared. More women than ever are willing to share their experience of sexual harassment and gender discrimination at all levels of training and practice. The response by many men in positions of power has been rather disturbing. Many of them have stopped meeting alone with women, and others will not meet with women they do not know well or who are considered to be their subordinates. In this #MeToo scenario, men's fear of mentoring builds on the notion that woman may not be perceptive enough to know the difference between a good or a bad intention and that any allegations of sexual misconduct could compromise their dignity and career, even if they were found to be innocent. This response can have a deleterious impact on women's career enhancement. Being denied mentor relationship by male seniors stops young women from career-flourishing experiences during critical periods of their professional development. Strategies can be implemented at organizational levels to help men move beyond this milieu and create a safe space where men and women can talk directly about any concerns regarding mentorship.
| Legal System|| |
The legal system of the country has lately been on a spree to encounter the social issues and has looked to pin down every social problem with a legal solution. It may be adultery, homosexuality, suicide, or providing medical care: we have legal control everywhere.
First of all, the Apex Court recently struck down Section 497 as “indirectly discriminatory” toward women. It is being argued that Section 497 of IPC supports, safeguards, and protects the institution of marriage, and as such, removing the deterrence would tantamount to decriminalizing the offense of adultery, thereby eroding the sanctity of marriage or would rather encourage adulterous behavior with deleterious social consequences. The fact remains that the law, as it stands, allows only for men to be prosecuted for adultery. Worse, it implicitly treats the woman involved as someone who does not have or cannot have a will of her own. However, there is nothing to deal with the contentious issue raised about making both men and women equally liable for the crime of adultery. An amendment in the law could have served better on both the fronts, rather than striking down the law alone. This could have disastrous implications, and only time will tell whether these amendments were necessary to strengthen the social fabric of the society. On a similar note, the past few years have been years of landmark judgments in context of Section 377 and homosexuality. The significant one came in 2017 when in response to a petition, the SC ruled that, “Section 377 is in violation of Right to Privacy and Right to Life as you can't restrict the freedom of consenting people as far as their freedom is not hurting anyone else”, and has quashed the provision against homosexuality. However, it has been argued that homosexuality or other forms of sex are not accepted and are criticized as these are against the law of nature and also said to be against the norms or morals of society and religion. Arguably, nothing can be prohibited on the basis of religion or norms prevalent in society. The repealing of the homosexuality law would require developing several sensitive competencies in the Mental Health Professionals for services to address specific needs of the LGBT Community.
Second are the concerns related to the recently passed MHCA, 2017 which has followed the Mental Health Act of 1987. While the Indian Lunacy Act of 1912 was passed with the main stress on preventing the society from dangerousness of mentally ill, the Act of 1987 imbibed into it the provisions regarding the rights of patients with mental illness. However, the implementation of the Act was poor owing to the complicated procedures, defects, absurdities, and poor health-care delivery system. It took us a good 30 years to realize those shortcomings and draft the new look MHCA of 2017. Highlights of the new Act include declaring mental health as the right of the individual, decriminalization of suicide, restricted use of the ECT, special clauses for women and children to admission, treatment, and sanitation and hygiene, in addition to the provisions of nominated representative and advance directive. The Act promotes community-based treatments and includes other systems such as AYUSH for mental health-care delivery. Furthermore, the provisions that decriminalize suicide and provide for mental healthcare and services for such persons with mental illness might go a long way in reducing the stigma attached with suicides. People will no longer feel the need to hide their suicidal thoughts and would be encouraged to talk about it with others, and this would help to seek professional help. However, few points need to be considered on the flipside too. An attempt to decriminalize suicide is supposed to handicap law enforcement agencies in dealing with persons who resort to fast unto death or self-immolation to press the Government or authorities to accept their unreasonable or illegitimate demands. There is a need for a clear distinction to be drawn between persons driven to suicide due to medical/psychiatric illnesses and those who just want to create pressure for acceptance of their demands. The current scenario along with certain provisions of MHCA can make working of a psychiatrist challenging and frustrating at times. In many meetings that we have conducted regarding the MHCA, the psychiatrists have found this to be too oppressive to work safely, and as such, many have cut down on their services out of scare. If such a scenario persists, many of the private mental health establishments will be shut down for indoor services making mental health care more challenging and depleted. The opinion that the current MHCA is just a cut paste law of the developed countries such as UK and hardly shows any relevance and utility in the country like India, where there is an acute shortage of mental health resources, infrastructure, and political will, has been gaining weight lately. The implementation, acceptance, and utility of the Act is quite demanding and challenging for all stakeholders.
| Issues Specific to Mental Health|| |
Mental health and well-being have gained prominence in India with the new laws. The stigma associated with the mental problems, the ubiquitous issue of addiction, poor scenario of mental health in the rural parts, and the rapid changes in the diagnostic systems are the issues specific to mental health thereby posing challenges for social psychiatrists to keep pace with the rapidly changing demands, structure, values, and pressures of the society.
The first issue to deal with in this already critical scenario of mental health in India is that of stigma. Stigma refers to a culturally influenced discrimination against those with psychiatric illnesses, their families, and their caregivers and is a matter of grave concern. This is because society in general has stereotyped views about mental illness and how it affects people, and this stereotypy has largely influenced media portrayal of the afflicted individuals. Social isolation, poor housing, unemployment, and poverty are all linked to the discrimination associated with mental ill health. Stigma and discrimination can trap people in a vicious cycle of poor help-seeking by the patients and poor willingness of the Government to support mental health. The fact that such negative attitudes appear to be so entrenched suggests that campaigns to change these beliefs will have to be multifaceted, going beyond just imparting knowledge about mental health problems to aggressively challenging existing negative stereotypes. We have to turn to methods other than awareness programs with an aim to promote events encouraging mass participation and social contact between individuals with and without mental health problems. The recent step to include mental health disorders for insurance is a welcome step by the Government but till now hardly any insurance company has come forward in this regard.
Second is the alarming epidemic of addiction in the society. Studies have suggested that reward is a powerful agent. irrespective of the source, be it chemical or an experience, it is associated with a threat of getting ambushed in the concept of an addiction. In this context with the issue of substance abuse, already creating rampage in our society, the rapidly expanding use of electronic communication has afflicted in us a host of new addictions, namely, internet addiction, shopping addiction or compulsive buying, video game addiction, and porn addiction. Social consequences include serious relationship problems (marital conflicts and divorce-cyber affairs), financial losses, impaired functioning at work owing to reduced attention span, poor academic performance, sleep deprivation, and related physical issues. The individual addiction problems, for example, internet gaming disorder although not included in diagnostic systems are of increased concern, due to their strong association with comorbidities such as mood disorders, mainly depression, anxiety disorder, and substance use disorder.
Third, important issue, which has not found the mention it deserves, is of overmedicalization and thereby involving the rapid changes in the diagnostic systems (ICD-11 and DSM-5). When we have a look at the DSM, beginning from 1932 and the recent addition of 2013, we find that it has thickened by around 800 pages and has added around 400 new disorders. A pharmaceutically driven urge to label everything by a name has been the root of this proliferation of disorders and this trend, although providing the framework to disseminate the knowledge one has gained and providing boundaries, has opened up the gates of overmedicalization in the form of diagnostic overshadowing, long-term institutionalization, and depriving patients of their legal capacity.
Finally, rural mental health care demands great attention as it is an established fact that mental health is the most neglected aspect of general well-being, particularly in rural areas. With the increase in population, other factors such as changing values and life-style, frequent disruptions in income due to crop failure, natural calamities (droughts and floods), and unemployment along with lack of social support are making rural areas more vulnerable to mental disorders. Considering the fact that nearly 70% of population lives in rural areas, with only about one-fourth of the health infrastructure, medical workforce, and other health resources, it may be surmised that the number of people affected with any mental and behavioral disorder would produce great challenge for the mental health care providers in the coming future.
| Conclusion|| |
The society is rapidly changing and imposing new challenges with every passing moment. Mental health professionals need to think proactively to face these challenges. Keeping in view the growing self-absorption and isolation, the biggest challenge will be building families and communities. There is a need to develop a mental health-care model, which is drawn by the patients' need and abilities. Many people with mental health problems struggle to navigate separately health, mental health, and social care services that are organized in vertical compartments with their own criteria and priorities for which they serve. A need-led model of service delivery will consider the user's perspective and provide an interface between health and community services. The legal frameworks are good but passing of laws is not enough to bring out the changes without the political and social will to implement them. Mental health legislations cannot meet those challenges on its own. Ill-perceived, under-resourced, badly implemented or frankly oppressive, and poorly supported legislations can make things worse.
IASP needs to address these issues and makes proper strategies to meet these challenges. IASP has successfully added two scientific activities in addition to the regular conference from this year. The first additional activity in the form of CME was conducted at the AIIMS, New Delhi on consultation-liaison psychiatry. The CME was attended by >200 participants. The second additional activity was conducted by Prof. U. C. Garg at Agra on “Parenting of School Children and Misuse of Social Media”. This community-based program was a huge success. I hope that these two additional activities; one mid-term CME and one community awareness program will become a regular feature in the forthcoming yearly calendars of events of IASP. I am now coming to the end of my term of office as President and I am pleased to be handing the mantle of office to Prof. Indira Sharma, our new President. I wish Professor Indira Sharma and the IASP office bearers the best in the continuation of our society's work ahead and take it to new pinnacles of success in the future.
We would like to thank Dr. Vivek Srivastava, Junior Resident, Institute of Mental Health, Pt. B. D. Sharma UHS, Rohtak.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.